Case #2 Answers:
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It is difficult from the history to date the onset of his atrial fibrillation; however, his putting on 8 lbs. and having symptoms and exams consistent with congestive heart failure would suggest the duration of this atrial fibrillation is likely more than 48-72 hours.
Hemodynamically stable. If unstable (hypotension, hypoperfusion), immediate cardioversion may have to be performed, as medication options may be limited.
This patient has CHF and structural heart disease and has many potential causes. The most notable are HTN, risk factors for CAD/MI, ETOH use. Also consider thyroid disease or excessive radiation exposure.
On examination, he had some component of hypertension and his PMI is displaced with an S3 gallop also suggesting something other than just pure hypertension with preserved systolic function. This is a dilated heart and this probably has been going on for a long time. The exam does not suggest a valvular heart lesion; however, we cannot rule out ischemia. He appears to be hemodynamically stable.
Rate control. This will be best accomplished by treating his CHF which will let the catecholamine level drop and his rate decrease. Diuretics and possibly nitrates would be good choices. Morphine may also help with comfort and venodilation. Beyond this, consider careful use of beta or Ca blocker in conjunction with digoxin. If needed, amiodarone.
Our goals should be:
a. Rate control: assess rate with exertion even if resting rate is ok.
b. Rhythm control: Rhythm control should be pursued if symptoms persist with adequate rate control. Plan for cardioversion after 3 weeks of adequate anticoagulation or by precardioversion TEE. As AF is likely to recur, long term suppression with an antiarrhythmic drug or ablation is appropriate.
c. Anticoagulation: Anticoagulation with heparin and Coumadin, or a NOAC is indicated. CHADS2=3; CHA2DS2VaSc>=3 (HTN, DM,CHF)