Jean, an 86-year-old female, is a new admission to a nursing home. She reports she has had a few years of chronic bilateral upper limb discolouration. On the left upper limb this is associated with tingling pain on light touch. The symptoms have worsened in the last few months since an episode of rapid AF associated with heart failure, which required hospital admission for amiodarone loading.

Her past medical history includes AF with left ventricular dysfunction, gastro-oesophageal reflux disease, osteoarthritis, constipation and diverticulitis. She has been taking amiodarone for rate control for 10 years and has been reasonably well controlled. She developed intolerable side effects with a trial of a beta-1 blocker.