Severe sinus node dysfunction in Old age male

A 83 year old male resident of Pondicherrry, South India came to the JIPMER hospital emergency department with  chief complaints of one episode of giddiness along with vomiting today afternoon. There is history of dyspnoea along with palpitation were present but there was no history of chest pain, perspiration, or loss of consciousness. Patient was a known case of diabetes mellitus, hypertension since last 20 years and was on regular medication. Patient was also a known case of coronary artery disease with triple vessel diseases for which he underwent coronary artery bypass graft in 2011 at private hospital. During evaluation in the emergency department patient pulse rate was 24 beats per minute, BP-140/80 mmhg. ECG done in the emergency department is shown below.

                                                                       ECG 1

Description of the ECG-Junctional escape beats at rate around 18 beats per minute present, escape beat is of RBBB morphology with QRS duration 120 msec,single sinus beat is visible with visible P wave, PR interval 200 msec, with QRS of RBBB morphology, QT interval nearly 520 msec QTc 285 msec, so the ecg is suggestive of severe sinus node dysfunction with sinus arrest. 

                                                                                ECG

Another ECG of the patient again showing severe bradycardia with sinus pause with feature suggestive of  severe sinus node dysfunction.

ECG of the patient was again repeated after ten minute and cardiac marker of the patient were sent.

                                                                                     ECG 3

Description of the ECG-Normal sinus rhythm at 80 beats per minute, normal axis, PR interval 160 msec, complete RBBB, ST elevation was present in lead V1-V4 but there were no reciprocal change in inferior lead (II,III,avF), and as compared to old ecg there was no fresh ST-T segment changes. 

Patient cardiac marker, Trop I was within normal limit. So in view of intermittent sinus node dysfunction patient was decided to put on holter monitor to confirm the diagnosis. 

Holter monitoring of the patient done, which is shown below

Holter monitoring of the patient shown sinus node arrest with sinus pause more than 3 seconds. Maximum pause was of 4.032 sec, so in view of severe sinus node dysfunction permanent pacemaker was inserted and patient was discharged in stable condition.

Thank you.