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After completing this case study, the reader should be able to:

  • Describe the cornerstones of atrial fibrillation (AF) treatment.

  • Determine therapeutic goals for managing AF in patients with heart failure.

  • Recommend an optimal agent for anticoagulation in AF patients with heart failure.


Chief Complaint

“Lately, I feel like my heart has been racing a bit. It really doesn’t bother me that much, but I wanted to have it checked out to be sure.”


Cooper Riley is a 64-year-old man with heart failure and a history of persistent AF who presents to his primary care physician complaining of palpitations that he first noticed 7 days ago. He reports that he is aware of the palpitations but that he has remained relatively asymptomatic. There has not been a noticeable change in his level of fatigue or exercise capacity during his normal daily activities. Mr Riley has had congestive heart failure for 6 years. For the past few years, his baseline exercise capacity would be described as slight limitation of physical activity with some symptoms during normal daily activities but asymptomatic at rest. He has a history of AF that was cardioverted to NSR and he has been on amiodarone to maintain NSR for the past 8 months. In the office today, Mr Riley’s ECG shows that he is in AF (see Fig. 21-1).


  • Hypertension

  • Persistent AF (previously in NSR with amiodarone therapy)

  • Heart failure with reduced ejection fraction (LVEF 35%)

  • Obstructive sleep apnea (AHI 28 events/hour), alleviated with CPAP therapy


Both parents are deceased. Father died from AMI at age 64. Mother died of breast cancer at age 70 years.


Mr Riley works as an accountant. He is married with two healthy children. He does not smoke but occasionally “drinks a few beers on the weekend.”


  • Carvedilol 6.25 mg PO BID

  • Digoxin 0.0625 mg PO once daily

  • Amiodarone 400 mg PO once daily

  • Furosemide 40 mg PO once daily

  • KCl 20 mEq PO once daily

  • Lisinopril 10 mg PO once daily

  • Warfarin 5 mg PO once daily

  • CPAP therapy (8 cm H2O) at night




Reports no change in level of fatigue, some exercise intolerance; no headache, lightheadedness, chest pain, angina, or fainting spells; 2+ pitting edema.

Physical Examination


Cooperative overweight man in ...

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