A 78-year-old woman comes to the physician following discharge from the hospital. One week ago, she had gone to the emergency department for palpitations, which she had experienced several times before, and she was diagnosed with atrial fibrillation with rapid ventricular response. The arrhythmia resolved spontaneously overnight, and the patient was discharged the following day. She has no chest pain or shortness of breath and has never had syncope.
Past medical history includes hypertension and hyperlipidemia. The patient's medications include aspirin, diltiazem, atorvastatin, and ramipril. She exercises most days of the week on a stationary bicycle for 20-30 minutes without any difficulty. The patient volunteers at a senior center and helps care for her husband with Alzheimer's dementia.
Blood pressure is 135/75 mm Hg, pulse is 75 and regular, and BMI is 25 kg/m². Cardiac auscultation shows no murmurs. Her lungs are clear. Distal pulses are normal and symmetric. There is no edema.
Electrocardiogram (ECG) shows normal sinus rhythm with no significant repolarization abnormalities. Transthoracic echocardiogram shows a mildly dilated left atrium, left ventricular ejection fraction of 55%, and mild mitral and tricuspid regurgitation.
Laboratory studies show a TSH of 2.9 µU/mL.
Which of the following is the most appropriate next step in management?

Question

Quizplus · Accepted Answer

11ec193a_9738_4edd_853d_7ba550b72d7f_MD0002_00 This patient presented with paroxysmal atrial fibrillation (AF) that has spontaneously converted to sinus rhythm. Systemic thromboembolism is a major cause of long-term morbidity in patients with AF. Treatment with warfarin or target-specific oral anticoagulants has been shown to significantly reduce the risk of embolization in patients at moderate to high risk for thromboembolic events. Recent guidelines have recommended the use of a modified CHA₂DS₂-VASc score for stroke risk assessment in patients with nonvalvular AF. This patient has a CHA₂DS₂-VASc score of 4 (female gender, age >75, and hypertension) and should be managed with anticoagulation to reduce the long-term risk of systemic embolization. anticoagulation (Choice A) Amiodarone is occasionally used for maintenance of sinus rhythm in patients with recurrent, symptomatic AF (rhythm-control strategy). This patient has spontaneously converted to sinus rhythm, and current evidence suggests no significant difference in the risk of systemic thromboembolism between the rate- and rhythm-control strategies. (Choice C) Beta blockers and/or calcium channel blockers are used for heart rate control in patients with persistent AF. This patient has converted to sinus rhythm and would not benefit from additional beta blocker therapy. (Choice D) An exercise stress test is used primarily to evaluate for coronary artery disease (CAD) in patients with suspicious symptoms. It is occasionally used to assess rate control in AF patients with exertional symptoms. But this patient is now asymptomatic and stress testing is not indicated. (Choice E) Transesophageal echocardiography is performed to evaluate for intracardiac thrombus (left atrium or left atrial appendage thrombus) in patients with AF who have not been adequately anticoagulated prior to cardioversion. It has no role in patients with paroxysmal AF who are in sinus rhythm. Educational objective: Warfarin or target-specific oral anticoagulants have been shown to significantly reduce the risk of embolization in patients with atrial fibrillation and moderate to high risk for thromboembolic events. The CHA₂DS₂-VASc score is recommended for assessment of stroke risk in patients with nonvalvular atrial fibrillation. __________

A 78-Year-Old Woman Comes to the Physician Following Discharge from the Hospital