A 52-Year-Old Woman Is Undergoing Screening Colonoscopy and Receives Midazolam

A 52-year-old woman is undergoing screening colonoscopy and receives midazolam for sedation.  Shortly after the procedure is started, she becomes tachycardic and hypertensive.  Blood pressure is 240/140 mm Hg, pulse is 180/min, and respirations are 22/min.  Oxygen saturation is 92% on 4 L by nasal cannula.  ECG shows atrial fibrillation with rapid ventricular response.  Fine crackles are heard at the lung bases.
The procedure is aborted and the patient is admitted to the cardiac care unit for further management.  Medical history is significant for chronic lower back pain, anxiety disorder, and chronic headaches.  Medications include acetaminophen as needed for pain.  She has had no previous surgeries.
The following day, she feels fine and wishes to go home.  Blood pressure is 112/70 mm Hg, and pulse is 78/min and regular.  ECG shows normal sinus rhythm with nonspecific ST-segment and T-wave changes.  Complete blood count, serum chemistries, and TSH are unremarkable.  Transthoracic echocardiogram shows mild left atrial enlargement and mild mitral regurgitation.  Left ventricular systolic function is normal.
Which of the following is the best next step in management of this patient?

A) Chronic anticoagulation
B) Electrophysiology study for an accessory pathway
C) Opioid abuse screening
D) Pheochromocytoma workup
E) "Pill-in-the-pocket" flecainide therapy

Correct Answer:

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