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A 69-year-old woman with a history of congestive heart failure and stroke presented
to the emergency department with sudden onset lightheadedness that led to a fall at
the grocery store and sustained head trauma. On physical examination, she was alert
and in mild distress. Her heart rate was 72 beats per minute and blood pressure was
196/70. A 12-lead electrocardiogram (ECG) showed normal sinus rhythm, first-degree
atrioventricular (AV) block, and right bundle branch block. She was admitted for management
of subdural hematoma which was noted on CT scan. A few hours later, patient experienced
multiple episodes of long pauses leading to syncopal episodes in bed. A 12-lead ECG
was obtained and is shown in Figure 1.
Figure 1A 12-lead electrocardiogram showing normal sinus rhythm, right bundle branch block,
and conducted PAC, followed by complete heart block. PAC = premature atrial complex.
