Lightheadedness, Fatigue, and Bradycardia Elias B. Hanna, MD, and D. Luke Glancy, MD* This electrocardiogram of a 62-year-old man with lightheadedness and fatigue shows sinus rhythm at a rate of 70 beats/min with slight sinus arrhythmia. There is a high-grade atrioventricular (AV) block with the sinus P waves dissociated from a regular ventricular escape rhythm which has a rate of 38 beats/min (Figure 1). The seventh and the last P waves are conducted to the ventricles with a PR interval of 0.20 seconds, and the QRS complexes have a typical left-bundle-branch-block configuration. The conducted QRSs reset the ventricular escape rhythm, which has a QRS duration of 0.11 seconds and a configuration resembling left anterior fascicular block. Thus, it appears that there is infranodal AV block with persistent block in the left bundle branch, high-grade block in the right bundle branch, and a

ventricular escape rhythm arising near the conduction system. There is frequent fusion of sinus P waves with the ventricular escape complexes. Because of symptomatic high-grade second-degree AV block, the patient underwent dual-chamber pacemaker implantation.1 Disclosures The authors have no conflicts of interest to disclose. 1. Pugazhendhi V, Ellenbogen KA. Bradyarrhythmias and packemakers. In: Fuster V, O’Rourke RA, Walsh RA, Poole-Wilson P, eds. Hurst’s the Heart. 12th edition. New York: McGraw-Hill, 2008: 1020e1054.

Figure 1. Electrocardiogram of a 62-year old man with lightheadedness and fatigue.

Section of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center and the Interim LSU Hospital, New Orleans, Louisiana. Manuscript received January 21, 2015; revised manuscript received and accepted January 27, 2015. See page 1320 for disclosure information. *Corresponding author: Tel: (504) 568-4711; fax: (504) 568-2127. E-mail address: [email protected] (D.L. Glancy). 0002-9149/15/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2015.01.563

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Lightheadedness, fatigue, and bradycardia.

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