Question

A 57 year old male presents with three weeks of fatigue. He denies depressed mood, palpitations, changes in bowel habits, syncope, or new medications. On physical examination, the patient's temperature is 36.7 C (98.6 F), pulse 100, and blood pressure 126/82. Peripheral pulses are 2+, but are noted to be irregularly irregular. Breath sounds are equal bilaterally, and there is no peripheral edema. Initial troponin I is not elevated. The patient is started on intravenous diltiazem, and an EKG is obtained. The patient's EKG is seen here. Which of the following is the most appropriate next step in the management of this patient?

A. Heparin and warfarin
B. Cardiac catheterization
C. Cardiac defibrillator implantation
D. Ibutilide
E. Electrical conversion

Answer 1

In a 57-year-old male with an irregularly irregular pulse indicative of atrial fibrillation and without acute ischemic signs, anticoagulation with heparin and warfarin could be the most appropriate next step to prevent thromboembolic events.

Correct option is E.

Step-by-step explanation:

A 57-year-old male presenting with fatigue and an irregularly irregular pulse, with an EKG performed after administration of intravenous diltiazem, suggests the possibility of atrial fibrillation. Given this clinical scenario, the presence of an irregularly irregular rhythm that is not accompanied by elevated troponin I, and no other acute symptoms, an appropriate next step would be to consider the management of this arrhythmia.

The presence of an irregular rhythm without acute ischemia as indicated by troponin levels might lead one to focus on rhythm control and the prevention of thromboembolism. The most appropriate next step in the management of this patient could be anticoagulation (A. Heparin and warfarin), which is recommended to prevent thromboembolic events in patients with atrial fibrillation.