A woman in her 60s with syncope and vomiting. Does she need a pacemaker?

 Written by Pendell Meyers with some edits by Steve SmithA woman in her 60s on chemotherapy presented to the Emergency Department for a syncopal episode just prior to arrival. She was walking to the bathroom when she suddenly felt nauseous and passed out. EMS was called by the patient ' s daughter, and en route to the ED she vomited twice. On arrival to the ED, she adamantly denies chest pain but says she ' s " just still not feeling well. " She had no prior known cardiac disease.Triage at 0755:The rhythm is most either atrial fibrillation with complete heart block and resulting junctional escape, or atrial flutter with very high degree (but constant) block. Remember, atrial fibrillation cannot result in regular ventricular rhythm if it is conducted through the AV node.The QRS has narrow normal morphology. There is almost 1 mm STE in III, but no STE at all in II or aVF. The T wave in III is hyperacute, and is biphasic up-down. Leads aVL and I show reciprocal findings (STD and TWIbiphasic down-up). Through the baseline wander, you can see the impression ofdownsloping STD in V2 indicating posterior extension. Interestingly, V3 then appears to have a hyperacutebiphasic down-up T wave,with hyperacute Ts in V3 and V4, but then V5 and V6 do not. All the biphasic T-waves suggest that there is some early spontaneous reperfusion happening.Overall, it is diagnostic of inferoposterior OMI, likely RCA occlusion, likely also explaining the acute bradydysrhythmia.The rh...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs