Cardiology Pre test

Cardiology
Questions
DIRECTIONS: Each item below contains a question or incomplete
statement followed by suggested responses. Select the one best response to
each question.
146. A 60-year-old male patient on aspirin, nitrates, and a beta blocker,
being followed for chronic stable angina, presents to the ER with a history
of two to three episodes of more severe and long-lasting anginal chest pain
each day over the past 3 days. His ECG and cardiac enzymes are normal.
The best course of action of the following is to
a. Admit the patient and begin intravenous digoxin
b. Admit the patient and begin intravenous heparin
c. Admit the patient and give prophylactic thrombolytic therapy
d. Admit the patient for observation with no change in medication
e. Discharge the patient from the ER with increases in nitrates and beta blockers
147. A 60-year-old white female presents with epigastric pain, nausea and
vomiting, heart rate of 50, and pronounced first-degree AV block on ER
cardiac monitor. Blood pressure is 130/80. The coronary artery most likely
to be involved in this process is the
a. Right coronary
b. Left main
c. Left anterior descending
d. Circumflex
148. You are seeing in your office a patient with the chief complaint of relatively
sudden onset of shortness of breath and weakness but no chest
pain. ECG shows nonspecific ST-T changes. You would be particularly
attuned to the possibility of painless, or silent, myocardial infarction in the
a. Advanced coronary artery disease patient with unstable angina on multiple
medications
b. Elderly diabetic
c. Premenopausal female
d. Inferior MI patient
e. MI patient with PVCs

146. The answer is b. (Fuster, 10/e, pp 1246–1264.) This patient presents
with unstable angina, a change from the previous chronic stable state in that
chest pain has become more frequent and more severe. Intravenous heparin
is indicated. Subcutaneous administration of low-molecular-weight heparin
(such as enoxaparin) is an alternative. There is no role for digoxin, as this
may increase myocardial oxygen consumption and exacerbate the situation.
Thrombolytic therapy is reserved for the treatment, typically within 6 h, of
ECG-documented myocardial infarction and does not reduce cardiac events
in the setting of unstable angina. A more aggressive approach is early interventional
cardiac catheterization with angioplasty and/or stent placement,
possibly in conjunction with glycoprotein IIb/IIIa inhibitors.

147. The answer is a. (Fuster, 10/e, pp 52, 88.) The right coronary artery
supplies most of the inferior myocardium and supplies the AV node in over
70% of patients. Thus occlusion of this artery can cause ischemia of the AV
node with AV block or bradycardia, as well as symptoms of an inferior MI
as seen in this patient. AV block can occur with anterior MI related to LAD
occlusion, but this generally implies a greater area of myocardial involvement
and hemodynamic instability.

148. The answer is b. (Braunwald, 15/e, p 1387.) The classic presentation of
acute myocardial infarction (MI) involves heavy or crushing substernal chest
pain or pressure. However, 15 to 20% of infarctions may be painless, with
the greatest incidence in diabetics and the elderly. Dyspnea or weakness may
initially predominate in these patients. Other presentations include altered
mental status, the appearance of an arrhythmia, or hypotension. Diabetics
are likely to have abnormal or absent pain response to myocardial ischemia
due to generalized autonomic nervous system dysfunction. The other choices
have no specific link to greater likelihood of a silent MI.

149. A 75-year-old African American female is admitted with acute
myocardial infarction and congestive heart failure, then has an episode of
ventricular tachycardia. She is prescribed multiple medications and soon
develops confusion and slurred speech. The most likely cause of this confusion
is
a. Captopril
b. Digoxin
c. Furosemide
d. Lidocaine
e. Nitroglycerin

150. Two weeks after hospital discharge for documented myocardial
infarction, a 65-year-old returns to your office very concerned about lowgrade
fever and pleuritic chest pain. There is no associated shortness of
breath. Lungs are clear to auscultation and heart exam is free of significant
murmurs, gallops, or rubs. ECG is unchanged from the last one in the hospital.
The most effective therapy is likely
a. Antibiotics
b. Anticoagulation with warfarin (Coumadin)
c. An anti-inflammatory agent
d. An increase in antianginal medication
e. An antianxiety agent

151. A 72-year-old male presents to the ER with the chief complaint of
shortness of breath that awakens him at night and also night cough. Further
questioning confirms recent dyspnea on exertion. As you pursue the
diagnosis of congestive heart failure using the Framingham criteria, you
note the physical exam findings below. Which of the findings is considered
among the less specific minor criteria?
a. Neck vein distention
b. Rales
c. S3 gallop
d. Positive hepatojugular reflux
e. Extremity edema

149. The answer is d. (Fuster, 10/e, pp 902–905.) While the clinical picture
itself could lead to these neurological symptoms, the only cardiovascular
medication on this list likely to do so is lidocaine. Lidocaine is particularly
likely to cause confusion in the elderly patient, for whom a lower dose of
the drug should generally be given. Other potential adverse effects of lidocaine
include tremor, convulsions, respiratory depression, bradycardia, and
hypotension.


150. The answer is c. (Braunwald, 15/e, p 1369.) The history and physical
are consistent with post–cardiac injury syndrome (in the past also known as
Dressler syndrome or postmyocardial infarction syndrome). This generally
benign self-limited syndrome comprises an autoimmune pleuritis, pneumonitis,
or pericarditis characterized by fever and pleuritic chest pain, with
onset days to 6 weeks post cardiac injury with blood in the pericardial cavity,
as after a cardiac operation, cardiac trauma, or MI. Therefore the most
effective therapy is a nonsteroidal anti-inflammatory drug or occasionally a
glucocorticoid. Infection such as bacterial pneumonia, which would require
antibiotics, would typically cause dyspnea, cough with sputum production,
and rales on lung auscultation. Pulmonary embolus, which would require
anticoagulation, would cause dyspnea and tachypnea, often in conjunction
with physical findings of heat, swelling, and pain in the leg consistent with
deep vein thrombosis. Angina or recurrent myocardial infarction is always a
concern post MI (and what the patient usually fears in this situation), but
the nature of the pain—here pleuritic rather than pressurelike—and the
unchanged ECG are fairly reassuring and mitigate against an increase in
antianginal therapy. Anxiety can be present but would not cause fever.

151. The answer is e. (Braunwald, 15/e, pp 1322–1323.) Use of the Framingham
criteria (eight major and seven minor) is one method by which to
organize the signs and symptoms for the diagnosis of congestive heart failure.
Major criteria include paroxysmal nocturnal dyspnea, neck vein distension,
rales, cardiomegaly, acute pulmonary edema, S3 gallop, increased
venous pressure, and hepatojugular reflux. Minor criteria include extremity
edema, night cough, dyspnea on exertion, hepatomegaly, pleural effusion,
vital capacity reduced by one-third from normal, and tachycardia of
120 or more beats per minute. In addition, weight loss of 4.5 kg or more
over 5 days of treatment may be considered as a major or minor criterion.
To establish a clinical diagnosis of congestive heart failure, at least one
major and two minor criteria are required


152. A 55-year-old patient presents to you with a history of having
recently had a myocardial infarction with a 5-day hospital stay while away
on a business trip. He reports being told he had mild congestive heart failure
then, but is asymptomatic now with normal physical exam. You recommend
which of the following medications?
a. An ACE inhibitor
b. Digoxin
c. Diltiazem
d. Furosemide (Lasix)
e. Hydralazine plus nitrates

153. A 26-year-old female is referred to you from an OB-GYN colleague
due to the onset of extreme fatigue and dyspnea on exertion 3 months after
her second vaginal delivery. By history, physical, and echocardiogram,
which shows systolic dysfunction, you make the diagnosis of postpartum
cardiomyopathy. Which of the following is correct?
a. Postpartum cardiomyopathy may occur unexpectedly years after pregnancy
and delivery
b. About half of all patients will recover completely
c. Since the condition is idiosyncratic, future pregnancy may be entered into with
no greater than average risk
d. The postpartum state will require a different therapeutic approach than typical
dilated cardiomyopathies

152. The answer is a. (Braunwald, 15/e, pp 1323–1327.) The administration
of an angiotensin converting enzyme inhibitor has been shown to
prevent or retard the development of heart failure in patients with left ventricular
dysfunction and to reduce long-term mortality when begun shortly
after an MI. This relates to inhibition of the renin-angiotensin system and
to reduction of preload and afterload. Other agents that might be considered
for prevention of deterioration of myocardial function include a beta
blocker, an angiotensin II receptor blocker, and/or an aldosterone antagonist
such as spironolactone. General therapeutic measures also include salt
restriction and regular moderate exercise. Digoxin is reserved for those
with clear-cut systolic dysfunction. Calcium channel blockers are not indicated
for heart failure or routinely post MI. Loop or thiazide diuretics are
administered in those with fluid accumulation. The nitrate-hydralazine
combination is an option in ACE inhibitor–intolerant patients.

153. The answer is b. (Fuster, 10/e, p 1958.) Postpartum (or peripartum)
cardiomyopathy may occur during the last trimester of pregnancy or within
6 months of delivery. About half of patients will recover completely, with
most of the rest improving. However, current advice is to avoid future pregnancies
due to risk of recurrence. Treatment is as for other dilated cardiomyopathies,
except that ACE inhibitors are contraindicated in pregnancy.

154. Yesterday you admitted a 55-year-old white male to the hospital due
to chest pain and ruled out MI. The patient tends to be anxious about his
health. On admission, his lungs were clear, and his heart revealed a grade
II/VI systolic crescendo-decrescendo murmur at the upper right sternal
border; cardiac enzymes were normal, and resting ECG showed right bundle
branch block with less than 1 mm ST segment depression. The idea of
performing a routine Bruce protocol treadmill exercise test (stress test) to
further assess coronary artery disease was considered, but rejected primarily
due to which of the following?
a. Anticipated difficulty with the patient’s anxiety (i.e., he might falsely claim chest
pain during the test)
b. Pulmonary embolus suspected as the primary diagnosis
c. Concern about the presence of aortic stenosis, a contraindication to stress testing
d. The presence of RBBB, with this baseline ECG change obscuring typical diagnostic
ST-T changes
e. Concern that this represents the onset of unstable angina with unacceptable
risk of MI with stress testing

154. The answer is c. (Fuster, 10/e, pp 469–470, 475–476.) Cardiac auscultation
suggests aortic stenosis, a contraindication to stress testing. This
could be evaluated further with echocardiography. Anxiety or suspected
angina would not preclude a stress test. Pulmonary embolus is not likely by
history and physical. ST segment depression is the most common stress
test–induced manifestation of myocardial ischemia. This type of change is
difficult to assess in the presence of any bundle branch block in which the
ST segment is already abnormal. However, updated American College of
Cardiology/American Heart Association guidelines do support the use of
exercise stress testing in RBBB if the ST segment depression is 1 mm or less.
Radionuclide imaging would need to be considered to assess for angina in
the setting of LBBB, WPW, paced rhythm, or RBBB with 1 mm resting ST
segment depression.

155. A 75-year-old patient presents to the ER after a sudden syncopal
episode. He is again alert and in retrospect describes occasional substernal
chest pressure and shortness of breath on exertion. His lungs have a few
bibasilar rales, and his blood pressure is 110/80. On cardiac auscultation,
the classic finding you expect to hear is
a. A harsh systolic crescendo-decrescendo murmur heard best at the upper right
sternal border
b. A diastolic decrescendo murmur heard at the mid-left sternal border
c. A holosystolic murmur heard best at the apex
d. A midsystolic click

156. A 72-year-old male comes to the office with intermittent symptoms
of dyspnea on exertion, palpitations, and cough occasionally productive of
blood. On cardiac auscultation, a low-pitched diastolic rumbling murmur
is faintly heard toward the apex. The origin of the patient’s problem probably
relates to
a. Rheumatic fever as a youth
b. Long-standing hypertension
c. Silent MI within the past year
d. Congenital origin

157. You are helping with school sports physicals and see a 13-year-old
boy who has had some trouble keeping up with his peers. He has a cardiac
murmur, which you correctly diagnose as a ventricular septal defect based
on which of the following auscultatory findings?
a. A systolic crescendo-decrescendo murmur heard best at the upper right sternal
border with radiation to the carotids; the murmur is augmented with transient
exercise
b. A systolic murmur at the pulmonic area and a diastolic rumble along the left
sternal border
c. A holosystolic murmur at the mid-left sternal border
d. A diastolic decrescendo murmur at the mid-left sternal border
e. A continuous murmur through systole and diastole at the upper left sternal
border

155. The answer is a. (Braunwald, 15/e, pp 1349–1350.) The classic
symptoms of aortic stenosis are exertional dyspnea, angina pectoris, and
92 Medicine
syncope. Physical findings include a narrow pulse pressure and systolic
murmur as described in option a (rather than the aortic insufficiency murmur
of option b, the mitral regurgitation murmur of option c, or the mitral
valve prolapse click of option d).
156. The answer is a. (Braunwald, 15/e, pp 1343–1345.) The history and
physical exam findings are consistent with mitral stenosis. Dyspnea may be
present secondary to pulmonary edema; palpitations are often related to
atrial arrhythmias (PACs, PAT, atrial flutter or fibrillation); hemoptysis may
occur as a consequence of pulmonary hypertension with rupture of
bronchial veins. A diastolic rumbling apical murmur is characteristic. An
accentuated first heart sound and opening snap may also be present. The
etiology of mitral stenosis is usually rheumatic, rarely congenital. Twothirds
of patients afflicted are women.
157. The answer is c. (Braunwald, 15/e, pp 207–211, 1260–1261,
1335–1336.) A holosystolic murmur at the mid-left sternal border is the
murmur most characteristic of a ventricular septal defect. Both the murmur
of ventricular septal defect and the murmur of mitral regurgitation are
enhanced by exercise and diminished by amyl nitrite. Options a, b, d, and
e describe the usual findings in aortic stenosis, atrial septal defect, aortic
insufficiency, and patent ductus arteriosus, respectively.

Items 158–159
158. A 40-year-old male presents to the office with a history of palpitations
that last for a few seconds and occur two or three times a week. There are no
other symptoms. ECG shows a rare single unifocal premature ventricular
contraction (PVC). The most likely cause of this finding is
a. Underlying coronary artery disease
b. Valvular heart disease
c. Hypertension
d. Apathetic hyperthyroidism
e. Idiopathic or unknown
159. Subsequent 24-h Holter monitoring in the preceding patient confirms
occasional single unifocal PVCs plus occasional premature atrial contractions
(PACs). The best antiarrhythmic management in this case is
a. Anxiolytics
b. Beta blocker therapy
c. Digoxin
d. Quinidine
e. Observation, no medication

158. The answer is e. (Braunwald, 15/e, p 1293.) PVCs are common in
patients with and without heart disease, and are detected in 60% of adult
males on Holter monitoring. Occasional unifocal PVCs do not suggest any
of the underlying diseases described.

159. The answer is e. (Braunwald, 15/e, p 1294.) Minimally symptomatic
PVCs do not require treatment. Antiarrhythmic therapy in this setting has
not been shown to reduce sudden cardiac death or overall mortality. A beta
blocker would be the best choice if symptoms began to interfere with daily
activities.

160. An active 78-year-old female has been followed for hypertension but
presents with new onset of mild left hemiparesis and the finding of atrial
fibrillation on ECG, which persists throughout the hospital stay. She had
been in sinus rhythm 6 months earlier. Optimal treatment by the time of
hospital discharge includes antihypertensives plus
a. Close observation
b. Permanent pacemaker
c. Aspirin
d. Warfarin (Coumadin)
e. Subcutaneous heparin

Items 161–162
161. A 36-year-old white female nurse comes to the ER due to a sensation
of fast heart rate, slight dizziness, and vague chest fullness. Blood pressure
is 110/70. The following rhythm strip is obtained, which shows


a. Atrial fibrillation
b. Atrial flutter
c. Supraventricular tachycardia
d. Ventricular tachycardia

162. The initial pharmacologic therapy of choice in this stable patient is
a. Adenosine 6 mg rapid IV bolus
b. Verapamil 2.5 to 5 mg IV over 1 to 2 min
c. Diltiazem 0.25 mg /kg IV over 2 min
d. Digoxin 0.5 mg IV slowly
e. Lidocaine 1.5 mg /kg IV bolus
f. Electrical cardioversion at 50 joules

160. The answer is d. (Braunwald, 15/e, p 1296.) Aspirin alone might be
sufficient for a stroke patient without the complicating factor of atrial fibrillation.
However, in patients with atrial fibrillation, in whom the risk of stroke
approaches 30%, therapeutic anticoagulation with warfarin (Coumadin)
reduces the incidence of future stroke to a greater extent than the use of
aspirin. This particular patient may be a candidate for medical or electrical
cardioversion, which requires pretreatment with Coumadin for 3 weeks (if
the atrial fibrillation has been present for over 48 h or is of unknown onset).
Alternatively, a transesophageal echocardiogram (TEE) could be performed
to exclude the presence of left atrial thrombus, followed by cardioversion and
then maintenance warfarin anticoagulation for 4 weeks.
161. The answer is c. (Fuster, 10/e, pp 809–812, 820–825, 837–841.)
Paroxysmal supraventricular tachycardia due to AV nodal reentry typically
displays a narrow QRS complex without clearly discernable P waves, with
a rate in the 160 to 190 range. The atrial rate is faster in atrial flutter, typically
with a classic sawtooth pattern of P waves, with AV conduction ratios
most commonly 2:1 or 4:1, leading to ventricular rates of 150 or 75/min.
Atrial fibrillation would show an irregularly irregular rhythm. Wide QRS
complexes would be expected in ventricular tachycardia.
162. The answer is a. (Fuster, 10/e, pp 812–815.) Vagotonic maneuvers
such as carotid massage or the Valsalva maneuver could certainly be tried
first. If these are unsuccessful, adenosine, with its excellent safety profile
and extremely short half-life, is the drug of choice for supraventricular
tachycardia at an initial dose of 6 mg. Dosage can be repeated if necessary a
few minutes later at 12 mg. Verapamil is the next alternative; if the initial
dose of 2.5 to 5 mg does not yield conversion, one or two additional boluses
10 min apart can be used. Diltiazem and digoxin may be useful in rate
control and conversion, but have a much slower onset of action. Electrical
cardioversion would be reserved for hemodynamically unstable patients.
Lidocaine is useful in ventricular, not supraventricular, arrhythmias.

163. A 65-year-old man with diabetes, on an oral hypoglycemic, presents
to the ER with a sports-related right shoulder injury. His heart rate was
noted to be irregular and the following ECG was obtained. The best immediate
therapy is


a. Atropine
b. Isoproterenol
c. Pacemaker
d. Electrical cardioversion
e. Digoxin
f. Diltiazem
g. Observation

164. While at the grocery store, you see an elderly lady slump to the floor.
Going to her aid, your first step in Adult Basic Life Support (CPR) should
be the following
a. Check for a carotid pulse
b. Assess breathing
c. Establish an airway
d. Determine responsiveness
e. Institute chest compression

165. In the ICU, a patient suddenly becomes unresponsive, pulseless, and
hypotensive, with cardiac monitor indicating ventricular tachycardia. The
crash cart is immediately available. The first therapeutic step among the
following should be
a. Amiodarone 300 mg IV push
b. Lidocaine 1.5 mg /kg IV push
c. Epinephrine 1 mg IV push
d. Defibrillation at 200 joules
e. Defibrillation at 360 joules

163. The answer is g. (Braunwald, 15/e, p 1287.) This ECG shows Mobitz
type I second-degree AV block, also known as Wenckebach phenomenon,
characterized by progressive PR interval prolongation prior to block of an
atrial impulse. This rhythm generally does not require therapy. It may be
seen in normal individuals; other causes include inferior MI and drug
intoxications such as from digoxin, beta blockers, or calcium channel
blockers. Even in the post-MI setting, it is usually stable, although it has
the potential to progress to higher-degree AV block with consequent need
for pacemaker.

164. The answer is d. (Cummins, 1/e, pp 5–6.) One cannot automatically
assume initially that an individual has had a cardiac or respiratory arrest.
Therefore, first determine responsiveness by tapping or gently shaking the
victim and shouting, “Are you OK?” Then proceed with the ACLS
approach. Shout or phone for help, then position the victim and yourself.
Follow this with the ABCDs (establishing the Airway, assessing Breathing,
assessing Circulation, and managing any need for Defibrillation).

165. The answer is d. (Cummins, 1/e, pp 77–78, 82–83.) The standard
approach to ventricular fibrillation or pulseless ventricular tachycardia
involves defibrillation with 200 joules, then 300, then 360, followed if
needed by epinephrine 1 mg IV push every 3 to 5 min. Persistent ventricular
fibrillation or pulseless ventricular tachycardia leads to consideration
of amiodarone 300 mg IV push or lidocaine 1.0 to 1.5 mg/kg IV push. In
addition, magnesium sulfate 1 to 2 g IV may be given in torsade de pointes
or when arrhythmia due to hypomagnesemia is suspected. Procainamide
up to 50 mg/min (maximum total 17 mg/kg) is given to patients with intermittent
return of a pulse or non-VF rhythm, but then recurrence of VF/VT.
A precordial thump may be considered in this setting, but there is insufficient
evidence to recommend its use or avoidance.

166. A 55-year-old African American female presents to the ER with
lethargy and blood pressure of 250/150. Her family members indicate that
she was complaining of severe headache and visual disturbance earlier in
the day. They report a past history of asthma but no known kidney disease.
On physical exam, papilledema and retinal hemorrhages are present. The
best approach is
a. Intravenous labetalol therapy
b. Continuous-infusion nitroprusside
c. Clonidine by mouth to lower blood pressure slowly but surely
d. Nifedipine sublingually to lower blood pressure rapidly and remove the patient
from danger
e. Further history about recent home antihypertensives before deciding current
therapy

166. The answer is b. (Braunwald, 15/e, p 1428–1429.) This patient manifests
malignant hypertension with diastolic blood pressure 130 and acute
(or ongoing) target organ damage. She shows one subset of such damage,
namely hypertensive encephalopathy, including headache, visual disturbance,
and altered mental status. Immediate therapy with nitroprusside is
indicated in the ICU setting, although it would be avoided if renal insufficiency
were present. Other options include intravenous nitroglycerin or
intravenous enalaprilat. Intravenous labetalol is often used in hypertensive
urgencies, but, as a beta blocker, it is relatively contraindicated in asthma.
An oral medication such as clonidine would be difficult and slow-acting
in a lethargic patient. Sublingual nifedipine is no longer advised due to
increased potential for overshoot hypotension with adverse cardiovascular
events such as MI or stroke, and ischemic optic neuropathy.

Items 167–168
An 18-year-old male complains of fever and transient pain in both knees
and elbows. The right knee was red and swollen for 1 day the week prior
to presentation. On physical exam, the patient has a low-grade fever but
appears generally well. There is an aortic diastolic murmur heard at the
base of the heart. A nodule is palpated over the extensor tendon of the
hand. There are pink erythematous lesions over the abdomen, some with
central clearing. The following laboratory values are obtained:
Hct: 42
WBC: 12,000/L
20% polymorphonuclear leukocytes
80% lymphocytes
ESR: 60 mm/h
The patient’s ECG is shown on the facing page.

167. Which of the following tests is most critical to diagnosis?
a. Blood cultures
b. Antistreptolysin O antibody
c. Echocardiogram
d. Antinuclear antibodies
e. Creatinine phosphokinase

168. Based on the data available, the best approach to therapy is
a. Ceftriaxone
b. Corticosteroids plus penicillin
c. Acetaminophen
d. Penicillin plus streptomycin
e. Ketoconazole


169. A patient has been in the cardiac care unit with an acute anterior
myocardial infarction. He develops the abnormal rhythm shown below.
You should

a. Give digoxin
b. Consult for pacemaker
c. Perform cardioversion
d. Give propranolol
e. Give lidocaine

167–168. The answers are 167-b, 168-b. (Braunwald, 15/e, pp
1340–1342.) This 18-year-old presents with classic features of rheumatic
fever. His clinical manifestations include arthritis, fever, and murmur. A
subcutaneous nodule is noted, and a rash of erythema marginatum is
described. These subcutaneous nodules are pea-sized and usually seen
over extensor tendons. The rash is usually pink with clear centers and serpiginous
margins. Laboratory data shows an elevated erythrocyte sedimentation
rate as usually occurs in rheumatic fever. The ECG shows evidence
of first-degree AV block. An antistreptolysin O antibody is necessary to
diagnose the disease by documenting prior streptococcal infection. Most
experts recommend the use of glucocorticoids when carditis is part of the
picture of rheumatic fever. Therefore, in this patient with first-degree AV
block, corticosteroids would be indicated. Penicillin should also be given
to eradicate group A -hemolytic streptococci.
169. The answer is b. (Braunwald, 15/e, pp 1287–1290.) The ECG shows
complete heart block. Although at first glance the P waves and QRS complexes
may appear related, on closer inspection they are completely independent
of each other, i.e., dissociated. Complete heart block in the setting
of acute myocardial infarction requires at least temporary, and often permanent,
transvenous pacemaker placement. Atropine may be used as a
temporary measure. You would certainly want to avoid digoxin, beta
blockers, or any other medication that promotes bradycardia. There is no
indication on this strip for cardioversion such as for atrial fibrillation/
flutter or ventricular tachycardia/fibrillation. Lidocaine would be relatively
contraindicated in that it might suppress the ventricular pacemaker, leading
to asystole.