Wed3November0903PM 3

A 56-year-old man has been admitted to the coronary care unit after suffering an anterior myocardial infarction. The nurse calls you to review him as his trace is changing on the monitor intermittently.

His observations have remained stable and he denies any symptoms other than a little light-headedness. He has been commenced on a few new medications, including bisoprolol, ivabradine, lisinopril, aspirin, clopidogrel and atorvastatin.

The nurse has taken a 12 lead trace of the worrying change in heart rhythm which she shows you:

Which of the following would be the most suitable line of management for this patient?

(Please select 1 option)

Temporary pacing wire This is the correct answer

Refer for implantable cardioverter defibrillator (ICD)

Observe

Stop the beta blocker Incorrect answer selected

Trial of atropine

Explanation

New-onset third-degree atrioventricular (AV) block (that is, complete heart block) is a medical emergency. Treatment can be gauged on presentation and history.

Recent MI, in particular anterior wall, indicates AV ischaemia and possibility of asystole. However, treatment with new AV node blocking drugs may also result in complete heart block and a trial of cessation would be warranted if the clinical scenario allowed.

Beyond this management should be focussed on initiating pacing of some kind. The symptomatic or high-risk patient may require immediate intervention with transcutaneous or temporary wire pacing, whilst the more stable asymptomatic patient is able to be observed whilst awaiting a permanent pacemaker or ICD insertion.

Answer Statistics

1

61%

2

4%

3

4%

4

23%

5

10%

Times answered: 269