An electrocardiographic rhythm strip revealed third-degree atrioventricular block with narrow QRS complexes. Following 1 mg of intravenous atropine sulfate the heart rate increased to 60 beats/ minute and the blood pressure rose to 110/70 mm Hg. He was warm and dry and no longer lightheaded. The patient was a heavy smoker who had been seeing his physician regularly because of recurrent upper gastrointestinal symptoms occurring predominantly in the morning hours. A gallbladder ultrasound examination disclosed no abnormalities and upper gastrointestinal tract series revealed a small sliding hiatal hernia without reflux. Therapy with an H2-antagonist yielded inconsistent results and the patient had been scheduled to undergo an exercise stress test. Earlier that day, he was awakened at 6:30 am by an insidious feeling of indigestion and nausea that improved partially after taking liquid antacids.
On arrival at the hospital an electrocardiogram revealed sinus bradycardia and ST segment elevation in the inferior leads consistent with an early pattern of acute myocardial infarction. A low-dose aspirin tablet was given and intravenous nitroglycerin and tissue-type plasminogen activator infusion were begun two hours after the syncopal episode. Hours later the electrocardiogram had normalized and the patient was asymptomatic. He was discharged on the sixth hospital day on a regimen of low-dose aspirin, propranolol, and oral nitrates. buy ampicillin
One month later cardiac catheterization revealed subtotal occlusion of the right coronary artery and 50 percent stenosis of the left anterior descending and circumflex arteries. He underwent successful single-vessel percutaneous transluminal angioplasty and was discharged from the hospital three days later on a regimen of low-dose aspirin, long-acting nitrates, and propranolol.
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