Management of Atrial Fibrillation in Patients Treated With Bruton's Tyrosine Kinase (BTK) Inhibitors

A 70-year-old man with chronic lymphocytic leukemia who started ibrutinib 3 months prior is referred from the hematology clinic to cardiology with new-onset palpitations and dyspnea on exertion.

Background history includes:

  • Hypertension
  • Diabetes mellitus type II
  • Stage III chronic kidney disease (creatinine 1.8mg/dL)
  • Obesity (body mass indez32 kg/m2)

Current medications include:

  • Amlodipine 5 mg once daily
  • Losartan 25 mg once daily
  • Metformin 500 mg twice daily

Physical examination is notable for:

  • Vital signs: blood pressure 124/74 mm Hg, heart rate 120 bpm, oxygen saturation 98%
  • Mildly elevated jugular venous pressure (~10cm H2O)
  • Irregularly irregular rhythm, no murmurs
  • Trace pretibial and ankle edema bilaterally

Electrocardiogram (ECG): Atrial fibrillation (AF) with rapid ventricular response at 124 bpm, nonspecific ST-T-wave abnormalities (Figure 1)

Figure 1

Figure 1

Which one of the following is the best strategy for rate control in this patient?

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