The patient has fulminant congestive heart failure (CHF), the etiology of which is unknown. It is possible that he has an undiagnosed cardiomyopathy (ischemic or idiopathic) and that an infection resulted in CHF and atrial fibrillation (AF). It is also possible that the AF is causing the CHF from tachycardia. Nevertheless, the AF is deleterious. Flecainide is an effective agent to convert atrial fibrillation, but it is contraindicated in this patient, because it increases mortality in patients with coronary artery disease (CAD) and heart failure. Cardioversion might be appropriate if AF is the primary cause of the CHF. Unfortunately, the patient cannot clearly identify when the AF began, so thromboembolic complications are a concern; anticoagulation should be initiated if no contraindications exist. With a stable blood pressure, a course of diuresis with administration of oxygen and anticoagulation is reasonable, because CHF and hypoxia may be a cause of his AF. Digoxin administered intravenously, along with cautious administration of low-dose, short-acting beta-blockers to achieve rate control (without exacerbating his failure) is reasonable.
- Administer flecainide.
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