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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 was diagnosed with heart failure 6 years ago. 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 (Fig. 26-1).

FIGURE 26-1.

Rhythm recorded in Mr Riley’s physician’s office that depicts AF with a ventricular response rate of 110 bpm. AF is characterized by the absence of atrial “p” waves with varying distances between QRS complexes. AF is sometimes referred to as an irregularly irregular rhythm: irregular because it is not NSR; irregular because it produces an irregular ventricular response rate or peripheral pulse.



Persistent AF (previously in NSR with amiodarone therapy)

Heart failure with reduced ejection fraction (LVEF 35%)

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


Both parents are deceased. Father died of an 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


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