In a patient who has had his or her first onset of atrial fibrillation (AF), would you advise medication, ablation, or rate control? The individual has normal BP and does not have an enlarged heart. — Ming Lin, ANP-BC, New York City

Rate control is an excellent starting point. AF is the most common arrhythmia a primary-care clinician faces, and there is a vast array of treatment options available. First is the individual assessment that addresses the patient’s symptoms, which range from none to pre-syncope and profound shortness of breath/fatigue. Second is the structure of the heart (left atrial dilation, ejection fraction). Third is the setting in which the AF occurred (surgery, stress, electrolyte imbalance, acute coronary syndrome or MI, thyroid, infection, random).

No therapy has been proven superior to another in a general sense, but a slow start is usually best. A simple plan includes anticoagulation (a must) and beta-blocker control with metoprolol (Lopressor, Toprol) or nebivolol (Bystolic), both of which can be used in patients with diabetes and metabolic syndrome. Reserve non-dihydropyridine calcium-channel blockers for individuals who cannot tolerate beta blockade and have normal ejection fractions. Patients with atrial flutter should have an electrophysiology consult, as ablation is indicated, but AF patients that are not highly symptomatic can be treated medically. Save anti-arrhythmics for highly symptomatic patients or those who fail on rate control, and refer those patients to cardiology or electrophysiology. In addition, consider cardioversion either after transesophageal echocardiogram or after four weeks of therapeutic anticoagulation. All AF patients need anticoagulation and require an echocardiogram, stress test, and labs (electrolytes and thyroid) in the initial workup. Comprehensive guidelines for the management of patients with AF were released in 2006 (Circulation. 2006;114:e257-354, available at, accessed March 15, 2013). — Maria Kidner, DNP, FNP-C (174-1)

These are letters from practitioners around the country who want to share their clinical problems and successes, observations and pearls with their colleagues. We invite you to participate. If you have a question, submit it here.