Scenario: An 81-year-old male with known coronary artery disease (CAD) was brought to the emergency department (ED) by his family after he suddenly fainted while watching television. After arrival to the ED, the patient was alert and oriented. He recalled feeling palpitations that preceded the spell. Below is his admission electrocardiogram (ECG). His most recent prior ECG showed normal sinus rhythm at 74/min. The patient has an automatic implantable cardioveter defibrillator (AICD) with a pacer that was placed a few years ago.

This 12-lead ECG shows fine atrial fibrillation (AF) with atrial and biventricular (A-BiV) pacing. Permanent A-BiV pacing is usually used in patients with advanced heart failure, which indicates extensive myocardial damage in this CAD patient.

His previous ECG showed normal sinus rhythm so the current AF is new, but unlikely to be the cause of the current syncopal attack — especially because A-BiV pacing is used as a...

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