Which of the following patients would be the best candidate to have a coronary artery bypass graft surgery (CABG)?

Choice A rationale

Setting the defibrillator in asynchronous mode and charging to 300 joules is contraindicated for synchronized cardioversion. Asynchronous shocks deliver energy regardless of the cardiac cycle, potentially striking during the vulnerable repolarization phase (T wave) and precipitating ventricular fibrillation. Synchronized cardioversion requires synchronized discharge on the R wave, using typically 50–100 joules for atrial flutter, ensuring depolarization of abnormal reentrant circuits without inducing malignant arrhythmias.

Choice B rationale

Gradual voltage increase until beats are captured describes pacing, not cardioversion. Electrical pacing delivers low-energy impulses to stimulate myocardial depolarization, used for bradyarrhythmias rather than atrial flutter. Cardioversion requires a single synchronized shock to terminate reentrant tachyarrhythmias by depolarizing cardiac tissue simultaneously, interrupting the abnormal conduction loop. Incremental voltage adjustment would be ineffective and potentially arrhythmogenic in tachydysrhythmic conditions.

Choice C rationale

Sedation before synchronized cardioversion prevents pain and anxiety because the electrical shock, though brief, causes skeletal muscle contraction and discomfort. Short-acting benzodiazepines or propofol are commonly administered per protocol. Cardioversion is synchronized with the R wave to restore sinus rhythm safely. Pre-procedure sedation ensures patient comfort, minimizes sympathetic stimulation, and prevents recall of the event while maintaining airway reflexes and hemodynamic stability.

Choice D rationale

Intubation is not routinely required for synchronized cardioversion in stable patients. Airway stabilization is necessary only if respiratory compromise or deep sedation occurs. Cardioversion is typically performed under short procedural sedation using non-paralyzing agents. Routine intubation would unnecessarily increase procedural risk and delay rhythm restoration in hemodynamically stable patients with atrial flutter. Continuous monitoring ensures airway protection without mandatory endotracheal intervention.

Choice A rationale

While statin medications are vital for lipid management and stabilization of atherosclerotic plaques in patients with coronary artery disease, an acute change in angina pattern is a much more immediate and life-threatening concern than the need for a new medication order. Statin use is a long-term strategy, not a priority response to acute symptom change.

Choice B rationale

Medication non-adherence is a common cause of symptom recurrence or worsening, yet the described change—more intense and prolonged pain—is the clinical definition of unstable angina. This acute coronary syndrome requires immediate intervention to prevent myocardial infarction and supersedes assumptions about patient compliance.

Choice C rationale

The change in the patient's chronic stable angina—new onset of more intense, longer-lasting chest pain—is the hallmark presentation of unstable angina. This indicates a critical shift, often due to a non-occlusive thrombus forming on a ruptured atherosclerotic plaque, demanding immediate emergency evaluation and treatment to prevent myocardial infarction.

Choice D rationale

High sodium intake exacerbates hypertension and can worsen heart failure symptoms by causing fluid retention, increasing cardiac workload. While dietary habits are important, an acute change in anginal pain pattern, suggestive of plaque instability and impending ischemia, is a far more immediate and critical concern than dietary salt intake. —.