When Rate Control Fails: A Case Challenge in the Management of a Complex Cardiac Arrhythmia in an Older Adult

J.D. is an 82-year-old man with a 12-year history of atrial fibrillation (AF), now long-standing persistent, who presents to his nurse practitioner (NP) with worsening symptoms consistent with New York Heart Association class III functional limitation,1 including 6 months of progressive fatigue and exertional dyspnea. Despite an exhaustive pharmacologic course including optimized rate-control agents, electrical cardioversion, and antiarrhythmic therapy, his ventricular rate remains poorly controlled, and his functional capacity continues to decline.