What is the best management plan for a patient with paroxysmal atrial fibrillation (A-fib), history of transient ischemic attack (TIA), and positive bubble study suggesting a patent foramen ovale (PFO) or atrial septal defect (ASD)?

Management of Paroxysmal Atrial Fibrillation with TIA and Positive Bubble Study

This patient requires continuation of anticoagulation with apixaban 5 mg twice daily indefinitely, transesophageal echocardiography to characterize the PFO/ASD, and referral to structural cardiology for consideration of percutaneous closure given recurrent TIA despite anticoagulation. 1

Anticoagulation Strategy

Continue apixaban 5 mg twice daily indefinitely regardless of PFO closure outcome. The patient has a CHA2DS2-VASc score of 3 (hypertension and two TIAs), which mandates oral anticoagulation. 1, 2 Direct oral anticoagulants like apixaban are preferred over warfarin due to lower bleeding risk, particularly lower intracranial hemorrhage rates. 3

• Anticoagulation must continue after any PFO/ASD closure procedure based on the CHA2DS2-VASc score, not the perceived success of the closure. 1 This is a critical point—the 2024 ESC guidelines explicitly state that continuation of oral anticoagulation is recommended after ablation or structural procedures according to the patient's stroke risk score, independent of rhythm outcome or left atrial appendage exclusion. 1

• The addition of aspirin following the second TIA should be discontinued once the patient is on therapeutic anticoagulation alone, as aspirin plus anticoagulation increases bleeding risk without proven additional benefit unless there is an acute vascular event. 2

PFO/ASD Evaluation and Closure

Proceed with transesophageal echocardiography to definitively characterize whether this is a PFO or ASD and assess suitability for percutaneous closure. 1 The strongly positive bubble study in the context of recurrent TIA despite anticoagulation suggests paradoxical embolism as the mechanism.

• Referral to structural cardiology for percutaneous closure is appropriate given the recurrent embolic events despite anticoagulation. 1 Recent evidence demonstrates that PFO closure in cryptogenic stroke reduces recurrence risk modestly but significantly. 4

• The 2024 ESC guidelines note that in patients with atrial septal defect and AF, closure may be performed before the fourth decade of life to decrease AF risk, and AF catheter ablation can be considered at the time of closure. 1 However, this patient is 45 years old, so the primary indication is secondary stroke prevention.

• Important caveat: Patients with stroke who underwent PFO closure may have an increased risk of AF post-procedure, requiring continued monitoring. 1

Rhythm Control Management

Continue flecainide 100 mg twice daily with atenolol 25 mg daily for paroxysmal AF rhythm control. 1, 2 The 14-day Holter showing no AF recurrence suggests good rhythm control, and the patient reports only rare palpitations (few times per month).

• Flecainide is appropriate for this patient as he has no structural heart disease (normal coronaries on catheterization, normal echo except mild-moderate LA enlargement, normal stress echo). 1 The 2024 ESC guidelines recommend flecainide or propafenone in patients requiring long-term rhythm control to prevent recurrence and progression of AF, specifically excluding those with impaired LV systolic function, severe LVH, or coronary artery disease. 1

• Atenolol must be continued as AV nodal blockade when using flecainide to prevent rapid ventricular response if atrial flutter develops. 1 The guidelines consistently emphasize that a beta blocker or nondihydropyridine calcium channel antagonist should be given before or with class IC agents to prevent rapid AV conduction. 1

• The current blood pressure being "low normal" is acceptable as long as the patient is asymptomatic. 1 Do not reduce atenolol dose given its dual role in rhythm control and preventing rapid conduction with flecainide.

Monitoring for Proarrhythmia

Monitor ECG for proarrhythmic signs with flecainide therapy. 1 The current ECG shows sinus bradycardia (rate 48) with left anterior fascicular block and QRS duration of 122 ms.

• Key warning: QRS widening >150% of baseline (>183 ms in this patient) indicates flecainide toxicity and requires dose reduction or discontinuation. 1 The current QRS of 122 ms is acceptable but requires monitoring.

• Risk factors for proarrhythmia with class IC agents include wide QRS duration (>120 ms—this patient is at the threshold), structural heart disease, depressed LV function, rapid ventricular response rate, rapid dose increase, high dose, and drug accumulation. 1

• The left anterior fascicular block is a conduction abnormality that warrants closer ECG monitoring, though it is not an absolute contraindication to flecainide in the absence of other structural disease. 1

Rate Control Assessment

The current heart rate of 48 bpm at rest is acceptable if the patient is asymptomatic and achieves adequate rate response with exercise. 3 The negative stress echo with excellent exercise capacity confirms adequate chronotropic response.

• Beta-blockers are first-line for rate control in AF patients. 2, 3 The target is physiological heart rate control both at rest and during exercise. 3

Chest Pain Evaluation

The chest pain occurring after eating greasy/spicy foods is likely non-cardiac (possibly biliary or esophageal). 1 The negative stress echo rules out ischemia, and the pain pattern (postprandial, not exertional) is inconsistent with cardiac etiology.

• Consider gastroenterology referral for evaluation of gallbladder disease or gastroesophageal reflux disease as suggested in the clinical note. 1

• The mild myocardial bridging in the mid LAD found on 2021 catheterization is not causing symptoms given the negative stress test and non-exertional pain pattern. 1

Follow-Up Plan

Schedule TEE within 2-4 weeks, followed by structural cardiology consultation based on TEE findings. 1

• Continue current medications: apixaban 5 mg twice daily, flecainide 100 mg twice daily, atenolol 25 mg daily. 1, 2

• Discontinue aspirin once confirmed on therapeutic anticoagulation without acute vascular indication. 2

• Repeat ECG at follow-up visits to monitor QRS duration and assess for proarrhythmic changes. 1

• If PFO/ASD closure is performed, anticoagulation with apixaban must continue indefinitely based on CHA2DS2-VASc score of 3. 1