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A 62-year-old woman who has been experiencing intermittent palpitations over the past 2 years is seen in your office for a second opinion. When she initially presented to her cardiologist, he obtained non-invasive rhythm monitoring and subsequently diagnosed her with paroxysmal atrial fibrillation. For the past year, she has been prescribed flecainide 100 milligrams twice daily, and metoprolol 25 milligrams per day. She states that this medication regimen was initially helpful. However, for the past two to three months, she has noticed that her episodes of palpitations are more frequent and longer in duration.

Her other medical history is significant for hypertension, obesity, with a BMI of 32 kg/m². And finally, she has made it clear that she's not interested in pursuing catheter ablation for atrial fibrillation at this time.

What is the best next step for her management?

  1. Change flecainide to amiodarone
  2. Refer to a weight loss clinic
  3. Recommend AV nodal ablation and permanent pacemaker implantation
  4. Catheter ablation for atrial fibrillation

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