A 72-Year-Old Man Comes to the Office Due to Palpitations

A 72-year-old man comes to the office due to palpitations, fatigue, and dyspnea for the past 2 weeks.  The patient experienced an episode of atrial fibrillation 4 years ago during hospitalization for pneumonia; the episode spontaneously resolved 2 days later.  Since then, he has had 3 episodes of symptomatic atrial fibrillation that self-terminated within a week.  Other medical history includes hypertension, type 2 diabetes mellitus, and chronic heart failure.  Blood pressure is 130/84 mm Hg and pulse is 110/min.  The lungs are clear to auscultation.  Cardiac examination demonstrates tachycardia with irregularly irregular heartbeats.  ECG confirms atrial fibrillation.  The patient's ventricular rate is controlled with beta blocker therapy, but the arrhythmia fails to resolve as in previous episodes.  Which of the following factors is most likely involved in the progression of this patient's arrhythmia?

A) Abnormal atrioventricular nodal pathway
B) Atrial structural remodeling
C) Cardiac autonomic neuropathy
D) Conduction system fibrosis
E) Enhanced sinoatrial node automaticity

Correct Answer:

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