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Medication reconciliation error — ABIM Board MCQ

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EasyGeneral Internal MedicineMedication reconciliation errorABIM Board

A 70-year-old man is admitted after a syncopal episode. He reports inadvertently taking both metoprolol succinate and carvedilol prescribed by different clinicians. His heart rate is 42/min, blood pressure is 128/74 mm Hg, and he is alert without chest pain or dyspnea. ECG shows sinus bradycardia without atrioventricular block or ischemic changes. Which of the following is the most appropriate next step?

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Correct answer: E — Withhold the beta blockers, monitor him, and reconcile his medication list

The correct answer is E. The patient has sinus bradycardia caused by inadvertent duplicate beta-blocker therapy, a reversible medication-related cause. Because he is currently alert, normotensive, and without ongoing ischemia, heart failure, or shock, the offending rate-slowing medications should be withheld while he is monitored. Medication reconciliation should identify the intended regimen and prevent recurrence at discharge. Atropine is appropriate when bradycardia produces ongoing hemodynamic compromise, not solely because the heart rate is below 50/min. Permanent pacing is not indicated before correction of a reversible cause. Continuing both beta blockers would perpetuate the adverse drug event, and thrombolysis is inappropriate without evidence of acute ischemic stroke or ST-elevation myocardial infarction.

Reference: American Heart Association. 2025 Guidelines for CPR and Emergency Cardiovascular Care, Part 9: Adult Advanced Life Support, Section 19, Initial Management of Bradycardia. 2025. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-advanced-life-support