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.