Scenario: Paramedics obtained this 12-lead electrocardiogram (ECG) from an 80-year-old white male with a medical history of coronary artery disease and recent myocardial infarction (< 6 months). The patient was attending morning church services, had a syncopal event, and was eased to the ground without trauma. A physician bystander reported that the patient was alert but diaphoretic with a pulse rate in the 20s. The patient was transported by ambulance to the emergency department. His blood pressure was 80/40 mm Hg, and intravenous atropine was administered en route but no change in heart rate was noted. The patient was alert, oriented, and denied associated symptoms of chest pain, nausea, vomiting or shortness of breath.

Atrial fibrillation with complete atrioventricular block and a ventricular escape rhythm

Progressive coronary artery disease with recent myocardial scarring could result in permanent injury to the electrical conduction system between the atria and the ventricles....

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