A 66-Year-Old Man with a History of Chronic Obstructive Pulmonary

A 66-year-old man with a history of chronic obstructive pulmonary disease (COPD) comes to the emergency department due to gradually worsening shortness of breath and wheezing for the past several days.  The patient also has a productive cough with mucoid sputum but no fever or chest pain.  His other medical problems include hypertension and hypercholesterolemia.  The patient has a 35-pack-year smoking history and quit 5 years ago.  Temperature is 37.1 C (98.8 F) , blood pressure is 130/80 mm Hg, and pulse is 114/min and irregular.  Pulse oximetry is 86% on room air.  Physical examination reveals moderate respiratory distress, bilateral expiratory wheezing, and distant heart sounds.  ECG shows an irregular narrow complex tachycardia with 3 different P-wave morphologies and a variable PR interval.  Serum electrolytes are within normal limits.  Which of the following is the best next step in management of this patient's cardiac arrhythmia?

A) Antiarrhythmic medication to convert to normal sinus rhythm
B) Anticoagulation and a calcium channel blocker
C) Monitoring while treating COPD exacerbation
D) Rate control with a nonselective beta blocker
E) Transesophageal echocardiogram and cardioversion

Correct Answer:

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