The correct answer is A!

This question is part of the Mayo Clinic Cardiology Board Review course.

A 66-year-old woman with a 4-year history of a non-ischemic cardiomyopathy presents with new onset of atrial fibrillation, detected on the last two ECGs that were performed one month apart. She is on optimal GDMT for her heart failure, which includes metoprolol succinate 150 mg and remains NYHA Class II. She has been unaware of the change in rhythm. A Holter monitor shows that she is in persistent atrial fibrillation and her average ventricular response is 80 bpm.

Q: In addition to anticoagulation, what is the next best step in her management?

  A) Continue GDMT for her heart failure (correct)

  B) Refer for pulmonary vein isolation

  C) Amiodarone load over four weeks followed by elective cardioversion

  D) TEE guided cardioversion after full anticoagulation


Similar to other patient populations, the main goals of therapy for those with AF and HF are prevention of thromboembolism and symptom control. In patients with HF who develop AF, a rhythm-control strategy is not superior to a rate-control strategy.


Roy D, Talajic M, Nattel S, et al. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358(25):2667–2677.

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