Scenario: A 59-year-old woman had brief episodes of rapid atrial fibrillation and bradycardia several months ago. It was not recurrent or sustained, so she was not treated with invasive or pharmacological interventions but followed up with occasional clinic visits. She was instructed to continue taking her beta blocker, which she had done for 10 years without side effects. She has a history of hypertension and a significant family history; her mother and grandmother had hypertension and heart failure, and both died of cerebral vascular accidents. The patient is now in the emergency department with complaints of chest “discomfort” and shortness of breath. She had the rhythm below (lead II), which was only captured because the patient’s daughter, a nurse, pushed the record button on the bedside monitor.

Third-degree heart block with an idioventricular escape rhythm at 36/min (first 6 beats), atrial capture beat...

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