This patient has evidence of an inferior-posterior ST-elevation myocardial infarction and should undergo urgent percutaneous coronary intervention (PCI). He is bradycardic with Mobitz type 1 second-degree heart block, also known as Wenckebach block. This type of atrioventricular block is almost always within the compact atrioventricular node (and not infra-Hisian) and in this patient is likely caused by right coronary artery occlusion. The right coronary artery supplies the atrioventricular nodal artery in 90% of patients. The most important intervention for this patient is urgent PCI and reperfusion of the infarct-related artery. Although the presence of atrioventricular block is usually transient and resolves with reperfusion, it is associated with worse prognosis and in-hospital survival.

Aminophylline increases cyclic adenosine monophosphate (cAMP) and can be used to promote atrioventricular conduction in patients with hemodynamically unstable bradycardia or advanced atrioventricular block (Mobitz type 2 second-degree or third-degree atrioventricular block) due to coronary ischemia. This patient is hemodynamically stable and his atrioventricular block is not advanced; therefore, aminophylline is not indicated.

Because the patient is not experiencing hemodynamic sequelae, low-dose dopamine infusion is not indicated. If the patient develops hemodynamically significant bradycardia, dopamine infusion could be used to stabilize him until coronary reperfusion and temporary pacing could be accomplished.

Advanced atrioventricular block in the setting of an acute coronary syndrome often requires temporary or permanent pacing. In this patient, temporary pacing is not indicated because he is hemodynamically stable and his block is not advanced. Decisions on permanent pacing should be delayed until a patient has been revascularized and stabilized to determine whether the arrhythmia persists.