A 46-year-old man comes to the physician with recurrent palpitations that wake him up at night. One year ago, he was diagnosed with paroxysmal atrial fibrillation. The patient had been treated with metoprolol, diltiazem, and flecainide in the past with temporary relief, but the symptoms had always recurred. Recently, flecainide was stopped, and he was started on sotalol. His other medical problems are hypertension and hyperlipidemia.
Electrocardiogram shows normal sinus rhythm with a QTC interval of 420 msec. Echocardiogram shows left atrial enlargement, mild mitral regurgitation, and left ventricular ejection fraction of 50%. A 24-hour Holter monitor shows episodes of atrial fibrillation with rapid ventricular rate.
Which of the following is the best next step to maintain sinus rhythm in this patient?

Question

A 46-year-old man comes to the physician with recurrent palpitations that wake him up at night.  One year ago, he was diagnosed with paroxysmal atrial fibrillation.  The patient had been treated with metoprolol, diltiazem, and flecainide in the past with temporary relief, but the symptoms had always recurred.  Recently, flecainide was stopped, and he was started on sotalol.  His other medical problems are hypertension and hyperlipidemia.
Electrocardiogram shows normal sinus rhythm with a QTC interval of 420 msec.  Echocardiogram shows left atrial enlargement, mild mitral regurgitation, and left ventricular ejection fraction of 50%.  A 24-hour Holter monitor shows episodes of atrial fibrillation with rapid ventricular rate.
Which of the following is the best next step to maintain sinus rhythm in this patient?

Quizplus · Accepted Answer

11ec193a_976e_a15f_853d_83a882c86410_MD0002_00 Antiarrhythmic drugs (AADs) are preferred over catheter ablation as first-line therapy for rhythm control in most patients with symptomatic atrial fibrillation (AF). However, catheter ablation for AF has rapidly evolved as an alternate therapy to AADs for rhythm control for patients who have failed AAD therapy. This patient has recurrent, symptomatic, paroxysmal AF despite the use of 2 separate AADs. The best next step in management is to refer the patient for AF ablation in an attempt to maintain long-term sinus rhythm. (Choice A) Digoxin inhibits conduction through the atrioventricular node. It is occasionally used to slow the ventricular rate in patients with AF, especially when therapy with beta blockers and/or calcium channel blockers is ineffective in adequately controlling the rate. It is not an AAD and does not reduce the frequency of AF episodes. (Choice B) A surgical Maze procedure for AF should be considered only in patients who are undergoing cardiac surgery for other indications (eg, valve repair/replacement, coronary artery bypass grafting). (Choice D) Mexiletine is a class 1B AAD used in the management of patients with refractory ventricular arrhythmias. It has no role in the management of patients with recurrent AF. (Choice E) Propafenone and flecainide ("pill in the pocket") are class IC AADs used in patients without structural heart disease for rhythm control of AF. This patient has failed flecainide for AF control, so propafenone is not likely to be effective in reducing the frequency of AF episodes. Educational objective: Catheter ablation is recommended in patients with symptomatic paroxysmal atrial fibrillation who have failed treatment or become intolerant to one or more antiarrhythmic drugs. __________ References: Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial. (http://www.ncbi.nlm.nih.gov/pubmed/24549549)

A 46-Year-Old Man Comes to the Physician with Recurrent Palpitations