DR REYNOLDS: Mrs B is a 60-year-old retired
teacher with atrial fibrillation (AF). She is married and has 2 daughters.
She lives near Boston and has commercial health insurance.
In December 2000, Mrs B experienced several self-limited episodes of
palpitations and throat tightness. A stress test was negative for anginal
symptoms or ischemic electrocardiogram changes at a high workload; a thyroid-stimulating
hormone test was within normal limits. In May 2001, she experienced a severe
episode of palpitations and was sent to a local emergency department where
she was found to be in AF with a moderate ventricular response. She was treated
with intravenous diltiazem and spontaneously converted to sinus rhythm. She
was referred to a cardiologist, who recommended aspirin and use of a β-blocker
as needed to control palpitations. An echocardiogram showed a mildly enlarged
left atrium, but was otherwise normal. A Holter monitor showed nonsustained
runs of atrial tachycardia, but no AF.