Shared decision making in atrial fibrillation: where we are and where we should be going.

You are seeing Mr Roberts, a 69-year-old retired office manager referred from the emergency department for treatment of atrial fibrillation (AF). He presented the previous night to the emergency department with shortness of breath and palpitations and was found to be in AF with a rapid ventricular response and a heart rate of 140 bpm. He was treated with intravenous diltiazem and spontaneously converted to sinus rhythm. He was then discharged from the emergency department with an outpatient cardiology appointment. He has a background history of hypertension but no other cardiac disease. His only medication is a thiazide diuretic. On questioning , he reports experiencing several episodes of palpitations over the last 2 to 3 years; typically, these are brief and self-limited. His transthoracic echocardiogram, thyroid studies , and electrolytes are all within normal limits. His ECG shows sinus rhythm with no other significant abnormality. His CHADS 2 score is 1 and CHA 2 DS 2-Vasc score is 2. He has a family history of gastrointestinal hemorrhage–associated death and is uncomfortable about long-term anticoagulation. Additionally, he is reluctant about taking a daily medication plus his blood pressure pill. How might you present current best practice while ensuring that his treatment program is consistent with his goals, values, and preferences?