Case #3 Answers

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Answer 1
Her condition worsened by the change from Metoprolol to Amlodipine due to loss of inadequate rate control.
 

Answer 2
It would be very unlikely to be successful at cardioversion and then maintenance of the long standing duration of atrial fibrillation.

Answer 3

CHA2DS2-VaSc= 9. Chronic anticoagulation should be recommended.

Answer 4
This patient should be treated with a rate control strategy, pharmacologically at first. If this fails, would recommend AV node ablation and insertion of single chamber vs BiV pacer (or ICD depending on LVEF and clinical status).