Atrial Fibrillation

I have two questions:

1.  If one is maintained on Coumadin and Toprol for Atrial Fibrillation (pulse=80bpm, but arrythmic)- Can longterm (many months to years) maintenance at an INR of 2.3 have serious side effects either in terms of bleeding or effects on the liver's
intrinsic ability to make clotting factors even after coumadin is discontinued.

2.  If there is some degree of enlargement of the heart or of the atria per se, and there is intermittent ankle swelling,is this suggestive of congestive heart disease?  And, is the use of Pronestyl to convert contraindicated if there is occult CHD?

I appreciate your answer to my questions.

[CCF CARDIO MD JMF]

Dear George,

There are no long term effects of betablockers and coumadin on the ability of the liver to clot.  

It is important to control your signs and symptoms of CHF as best as possible inorder to maintain sinus rhythm if that is the goal.  I generally recommend a couple of tries at cardioversion to acheive sinus rhythm in everyone.  Pronestyl is not contraindicated in CHD and is often used in the hospital.  However for long term maintainence of sinus rhythm in patients with CHF we generally  use Amiodarone in low doses (200 once a day)