A man in his 50s w/ ESRD, HTN, afib on metoprolol/warfarin, and history of TR s/p valve replacement presents with 1 week of palpitations and s/s of heart failure, found to have persistant rate-controlled afib and newly decreased EF of unclear etiology. Stay tuned – sounds like this case is still evolving and we may have an answer soon!
*Take home points: 1) Know the common causes of new/worsening afib 2) Review data on rate versus rhythm control*
Rate versus rhythm control:
*As Moyukh pointed out, data has showed no mortality benefit with rhythm control versus rate control; rate control continues to be recommended as first-line treatment due to ease of medication regimen and decreased drug-related side effects http://www.nejm.org/doi/pdf/10.1056/NEJMoa0708789
*For patients that continue to be symptomatic when rate-controlled, it is reasonable to consider rhythm control. Even if not in RVR, afib can itself cause decreased LV systolic performance and hemodynamic changes due to 1) loss of atrial systole required for optimal ventricular filling 2) activation of neurohormonal vasocontrictors 3) increased MR