Asymptomatic atrial fibrillation: problems of management.

A 78-year-old man presented to his personal physician for a yearly examination. He was totally asymptomatic. Findings of a physical examination performed 1 year previously were normal, and an ECG displayed normal sinus rhythm (NSR) and minor nonspecific T-wave changes. Five years previously, he was found to have mild systemic hypertension and was administered combined hydochlorothiazide (25 mg) and triamterene (37.5 mg) daily with satisfactory control of the BP throughout this time period. Physical examination disclosed a BP of 140/80 mm Hg and an irregular cardiac rhythm, at the average rate of 115 beats/min. The cardiac findings were otherwise normal, and the remainder of the general examination was also normal. ECG disclosed atrial fibrillation (AF) with a moderate ventricular response rate of 100 to 120 beats/min. Minor T-wave abnormality was again found but did not differ significantly from previous patterns. An echocardiogram was performed and demonstrated a normalsized left ventricle with a normal contraction pattern (estimated ejection fraction, 56%). This chamber demonstrated mild hypertrophy (wall thickness, 1.3 cm). Mild left atrial dilatation was observed (diameter, 4.2 cm), and the remainder of the examination was normal, including the absence of flow abnormalities by intracardiac Doppler echocardiographic interrogation. Additional test results included a normal chest radiograph and a normal blood profile (CBC count, general chemistry values, electrolytes, and lipid profile).