37.An 82-year-old woman is brought to the ED by her daughter for wors-
ening fatigue, dizziness, and lightheadedness. The patient denies chest
pain or shortness of breath. She has not started any new medications. Her
BP is 140/70 mm Hg, HR is 37 beats per minute, and RR is 15 breaths per
minute. An IV is started and blood is drawn. An ECG is seen below. Which
of the following is the most appropriate next step in management?
20 Emergency Medicine
a. Bed rest for the next 48 hours and follow-up with her primary-care physician.
b. Administer aspirin, order a set of cardiac enzymes, and admit to the cardiac care
unit (CCU).
c. Place a magnet on her chest to turn off her pacemaker.
d. Admit for Holter monitoring and echocardiogram.
e. Place on a cardiac monitor, place external pacing pads on the patient, and admit
to the CCU.
38.A 22-year-old man presents to the ED with a history consistent with
an acute MI. His ECG reveals ST elevations and his cardiac biomarkers are
positive. He has been smoking half a pack of cigarettes per day for the last
3 months. He drinks alcohol when hanging out with his friends. His grand-
father died of a heart attack at 80 years of age. The patient does not have
hypertension or diabetes mellitus and takes no prescription medications.
A recent cholesterol check revealed normal levels of total cholesterol, low-
density lipoprotein (LDL), and high-density lipoprotein (HDL). Which of
the following is the most likely explanation for his presentation?
a. Cigarette smoking
b. Family history of heart attack at age 80 years
c. Incorrectly placed leads on the ECG
d. Undisclosed cocaine use
e. Alcohol use
(Reproduced, with permission, from Fuster V et al.Hurst’s The Heart. New York, NY: McGraw-Hill,
2004: 904)