I recently diagnosed atrial fibrillation in a 24-year-old man with new-onset chest pain, irregular palpitations, and heart rate >170 beats per minute. The patient has no history of drug or tobacco abuse but does admit to binge drinking. Since he doesn’t want to take medications for the rest of his life, the plan is to cardiovert him. Should I put him on warfarin alone or on a combination of low-molecular-weight heparin with warfarin prior to the cardioversion procedure?
—Katharyn Madiwale, DO, Birmingham, Ala.

I agree with the cardioversion plan, but first make sure hyperthyroidism is not the cause of his atrial fibrillation. Use a beta blocker to both slow his ventricular rate and treat possible ischemic heart disease since he complained of new-onset chest pain with his fast heart rate. He should be anticoagulated with warfarin for three weeks (international normalized ratio 2-3) before attempting electrical cardioversion. During this period, it might not be a bad idea to obtain a stress test since he was symptomatic with chest pain. Anticoagulation should continue for one month after successful cardioversion to prevent emboli formation due to delayed atrial mechanical function (Am J Cardiol. 1998;82:1368-1371).
—Peter F. Cohn, MD (119-19)