A 60-year-old man presents with complaints of palpitations over the past 6 months. He feels his heart pound for several minutes to hours daily, which makes him short of breath when he plays golf. He brings a diary to his appointment today showing his daily blood pressure and heart rate readings, with a blood pressure ranging from 90-110 mm Hg systolic and 60-70 mm Hg diastolic, and a heart rate of 90-130 bpm; his home monitor indicates it is irregular most of the time.

His past medical history includes coronary artery disease, diabetes type 2, and hypertension. Medications include aspirin 81 mg daily, lisinopril 20 mg daily, metoprolol 25 mg twice daily, and metformin 500 mg twice daily. He has read on the Internet that an irregular heart rate usually means the heart is in atrial fibrillation and that a stroke may occur. He comes to you to find out if he should be initiated on anticoagulation. In the office, you also note an irregular rhythm, and the following 12-lead electrocardiogram (ECG) is obtained (Figure 1).


Which of the following is the next best step in management of this patient?

  1. Initiate warfarin and arrange for cardioversion in 3-4 weeks.
  2. Increase metoprolol to 50 mg twice daily and repeat ECG in 7-10 days.
  3. Refer for catheter ablation.
  4. Initiate amiodarone and repeat ECG in 2-4 weeks.
  5. Obtain a Holter monitor.

Correct answer: C


This ECG shows atrial tachycardia with Wenckebach block. The atrial rate is about 140 bpm. Atrial activity is best seen in this case in the inferior limb leads. Atrial tachycardia is usually difficult to treat successfully pharmacologically, and in this patient, increasing metoprolol may lead to further hypotension. Anticoagulation is not needed for atrial tachycardia. The best course of action is to refer for catheter ablation, which is usually curative. The focus of this atrial tachycardia is likely to be in the right atrium (given the negative P wave in lead V1), which carries a high likelihood for success and low risk for complications.


  1. Blomström-Lundqvist C, Scheinman MM, Aliot EM, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias): developed in collaboration with NASPE-Heart Rhythm Society. J Am Coll Cardiol 2003;42:1493-531.

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