A 65-year-old man presents with recurrent syncope. ECG shows right bundle branch block with left anterior fascicular block and a PR interval of 0.26 sec. What is the most appropriate definitive management?

• A Atropine 0.5 mg IV as needed
• B Observation and repeat ECG in 6 months
• C Oral theophylline
• D Permanent pacemaker implantation ✓

Explanation

Bifascicular block (RBBB + LAFB) plus first-degree AV block constitutes trifascicular disease. When associated with syncope, this carries high risk of progression to complete heart block. ESC and ACC/AHA guidelines recommend permanent pacemaker implantation. Atropine is only for acute temporary management of hemodynamically significant bradycardia.

Reference: Braunwald's Heart Disease, 12th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.