For an 80 year-old female with syncope and a heart rate of 40 bpm, what is the treatment of choice?

In the case of an 80-year-old female presenting with syncope and bradycardia (heart rate of 40 bpm), the most appropriate treatment is the insertion of a permanent dual chamber pacemaker. This is due to the fact that severe bradycardia, particularly when symptomatic (evidenced by syncope), often requires a more definitive intervention to prevent recurrent episodes and complications associated with low heart rates.

A dual chamber pacemaker helps maintain heart rate by stimulating both the atria and the ventricles, ensuring coordinated heart contractions and improving the overall cardiac output, especially important in older patients who may have additional comorbidities. In patients with symptomatic bradycardia, especially those who have experienced syncope, a pacemaker is often indicated to restore a normal heart rate and prevent future episodes of syncope.

While atropine can be used as an initial treatment for symptomatic bradycardia, it is generally not the definitive solution, especially in cases where there is a high risk of recurrent syncope. The other options, such as cardio defibrillator insertion and Ritalin therapy, are not appropriate for treating bradycardia-related symptoms and would not address the root cause of the patient's condition.