Rhythm Puzzle: A Patient with Dizziness.

A 78-year-old man presents with dizziness for 3 days. This lasts for 30 s to 1 min; he does not feel palpitations and has no other cardiac symptoms.

Nine years ago, he was analysed for chest pain; exercise testing and echocardiography were normal. His further medical history reveals depression and hemi-colectomy because of colon carcinoma. Current medication consists of aspirin, lisinopril, simvastatin, lithium carbonate, nortrilen, pantozol, alprazolam and movicolon.

Physical examination revealed a slow regular pulse of 40 beats/min with a blood pressure of 110/60 mmHg, and investigation of heart and lungs was within normal limits. The ECG on admission is shown in Fig. 1. Laboratory examination showed a normal blood level of lithium and nortrilen. The echocardiography showed normal left ventricular function with a mild aortic stenosis.

Fig. 1

ECG on admission (25 mm/s, 10 mm/mV)

What is your interpretation of the ECG? ■

Answer

You will find the answer elsewhere in this issue.