Scenario: This electrocardiographic (ECG) rhythm strip was obtained from a 74-year-old man who arrived at the emergency department (ED) with expressive aphasia and right-sided weakness. Consistent with a transient ischemic attack (TIA), his symptoms lasted 30 minutes and had resolved just prior to hospital arrival. He had experienced similar episodes in the past month. A recent ultrasound estimated a 70% stenosis of the left internal carotid artery (LICA). A computed tomography angiogram upon ED arrival confirmed a 90% stenosis in the LICA and severe stenosis bilaterally in his vertebral arteries. He has a history of hyperlipidemia, type II diabetes, and coronary artery bypass surgery 3 years ago. During the recording of this cardiac rhythm, he was alert, oriented and vital signs remained within normal limits.

This is sinus bradycardia (10 second average heart rate equals 54/min) with frequent premature atrial contractions (PACs); 2...

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