Electrocardiogram of an 80 year-old man with hyperlipidemia, coronary artery disease, remote myocardial infarction and recurrent episodes of presyncope.

Rate 60/min
PR 0.24 sec
QRS 0.15 sec
QT 0.44 sec
QRS axis – 80º

Interpretation: Abnormal ECG. Sinus rhythm with frequent unifocal PVCs. First degree AV block. Borderline left atrial abnormality. Left axis deviation. Left anterior fascicular block. Right bundle branch block with secondary repolarization abnormalities. Possible left ventricular hypertrophy.

The ECG documents trifascicular block. In ER the patient had periods of high degree AV block (several non-conducted P waves). He underwent permanent pacemaker implantation (VVIR) with active fixation lead. Few positions of the lead in the RV were explored before satisfactory capture was found probably because of presence of scar for previous myocardial infarction.

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