A 67-year-old man is presenting to the Emergency Department feeling dizzy and weak. During the past 6 months he has suffered from episodes of paroxysmal atrial flutter and atrial fibrillation and had been on metoprolol and amiodarone. He had become free of palpitation, but recently he had felt occasionally weak and dizzy and had noted his pulse to be slow. He was not on digoxin:

• Junctional bradycardia, 35/min

The patient was admitted and an AV sequential pacemaker was implanted. He was kept on metoprolol and amiodarone, and subsequently remained free of palpitation.