Middle age female with sinus node dysfunction

A 43 years old female resident of Villupuram, Tamilnadu came to JIPMER Hospital Cardiology OPD with  chief complaints of atypical chest pain since last 6 month, which was left side in location, severe in intensity, occur on and off , was not associated with any palpitation, vomiting, radiation or refernce of pain or any reliving or aggravating factor. Patient was also giving history of dyspnoea on exertion on and off since last 6 month but there was no history of orthopnoea or paroxysmal nocturnal dyspnoea.Patient was a known case of diabetes mellitus and hypertension since the past 2 years and she was on oral medication. There was no  history of beta blocker intake for the hypertensionn. During evaluation in the OPD patient pulse was 60 beats per minute, blood pressure was 100/60 mmhg. Cardiovascular system S1S2 were present, Respiratory system Bilateral normal vesicular sound were present. ECG of the patient done which  is shown below.ECHO heart suggestive of moderate tricuspid regurgitation with right ventricular systolic pressure 42 mmhg. 

ECG 1(Click on the image to  enlarge it)

Description of the ECG-Heart rate 60 beats per minute, Sinus rhythm present with rate around 75 beats per minute, narrow QRS complex, QT interval 460 msec, Corrected QTc interval 510 msec, there were no ST-T wave changes seen, intermittent long sinus pause are present with junctional escape beats with narrow QRS morphology with retrograde P wave merged into the end of QRS complex so on the  basis of this ECG provisional diagnosis was Symptomatic sinus bradycardia.

 Patient underwent holter monitoring for further conform the diagnosis. Holter strips are given below.

Holter strip 1

                    Holter is showing long sinus arrest, sinus pause in above strip was 3.6 second

Holter strip 2

Holter showing long sinus pause with maximum interval being 2.878

Holter strip 3

Holter showing long sinus pause with maximum interval of sinus pause being 1.8 second.

So in the view of sinus pause and history of breathless diagnosis of symptomatic sinus bradycardia was kept. Patient was implanted permanent pacemaker and she was later discharged in stable condition. 

Thank you.