Scenario: This is an electrocardiogram (ECG) rhythm strip of lead II from a 67-year-old male who was admitted to the cardiac intensive care unit with an acute onset of chest pain after painting his home. He is being evaluated for acute coronary syndrome (ACS). The patient has a history of dilated cardiomyopathy (DCM) from alcohol and drug abuse. However, he says he has not used drugs or alcohol in more than 10 years. His initial cardiac troponin (cTnl) was 0.05 ng/mL (reference point for ACS > 0.04 ng/mL). The nurse activated the ST-segment monitoring software on the bedside electrocardiographic monitor, but is frustrated because of multiple alarms due to ST-segment changes.

This rhythm is atrial flutter/fibrillation with bigeminal premature ventricular complexes (PVCs), and is commonly seen in patients with DCM. The initial narrow QRS complexes appear to have 2 P waves in front...

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