Clinical Presentation
77-year old male with a past medical history of hypertension, vascular dementia, hyperlipidemia, peripheral neuropathy, major depressive disorder, and 1st degree AV block was brought to the hospital from nursing home for bradycardia with heart rate of 32 BPM. Per records, patient sustained a fall at the nursing home two days prior to hospital admission. Patient had no prior history of falls or bradycardia. Patient had no history of taking any medication known to cause AV conduction delay. Physical exam was noted for bradycardia, clear breath sounds bilaterally, and neurologically patient was alert and oriented to self only. Initial EKG was noted for 3rd degree AV block with junctional escape rhythm, right bundle branch block with left anterior fascicular block, and HR of 30 BM (Figure 1 ). Chest x-ray was noted for some bilateral airspace opacities (Figure 2 ). Initial troponin was 0.018 ng/mL. BUN 30 mg/dL. Creatinine 1.42 mg/dL. BNP 892 pg/mL. Atropine was given and it transiently increased the HR to 50 BPM and the HR subsequently dropped to high 20s BPM. Cardiology evaluated the patient and he was taken to cardiac catheterization lab for an emergent temporary transvenous pacemaker. Patient subsequently had permanent pacemaker implanted electively.