I have an question regarding the symptomatic tachy/brady directive. A patient with a hx of atrial fibrillation, currently in a rapid afib at 180 BPM. But they have periods of chest pain and pre-syncope every minute or so due to a sinus arrest lasting approximately 8-9 seconds before they flip back into rapid afib. My understanding is that sick sinus syndrome is often the culprit, which can cause alternating rhythms on an ECG and needs to be treated in hospital. In terms of ACLS and pre-hospital care, which would be most appropriate? cardioversion or pacing? providing indications are met and the pt is unstable. Hypothetically, in different scenario, a patient with an underlying regular/brady rhythm and prolonged symptomatic runs of Vtach. What would be most appropriate in that scenario? Any input you could provide is greatly appreciated! Thanks