A 42-Year-Old Woman Is Evaluated for Palpitations

A 42-year-old woman is evaluated for palpitations.  She describes them as an occasional "fluttering in the chest" that is sometimes precipitated by emotion.  Her lifestyle is sedentary, but she has had no shortness of breath, cough, or lower extremity swelling and no history of bleeding.  The patient emigrated from Mexico when she was 6 years old.  She is a lifetime nonsmoker and does not drink alcohol.
Blood pressure is 135/85 mm Hg.  ECG shows a normal sinus rhythm with a heart rate of 65/min.
Resting transthoracic echocardiogram shows moderate left atrial dilation, mitral stenosis with a valve area of 1.5 cm², pliable leaflets with minimal calcification, mild mitral regurgitation, normal right ventricle size, and an estimated pulmonary artery systolic pressure of 25 mm Hg.  Two episodes of atrial fibrillation lasting 20 minutes each are seen on 24-hour Holter monitoring.
What is the best next step in management of this patient?

A) Anticoagulation with rivaroxaban
B) Anticoagulation with warfarin
C) Low-dose aspirin
D) Risk assessment using CHA₂DS₂VASc score
E) Transesophageal echocardiography

Correct Answer:

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