An 85-year-old man presents to the Emergency Department because of severe urinary retention secondary to prostatic carcinoma. The patient had an aorto-coronary bypass surgery 10 years earlier. He was diagnosed with Alzheimer’s disease one year ago and lives alone, and has been refusing medical follow-up:

• Atrial flutter with 2:1 AV conduction
• Ventricular rate 128/min
• Left axis deviation
• Left anterior fascicular block
• Non-specific ST abnormality

On collateral history, it was found that patient had previously been in atrial flutter and had been prescribed a beta-blocker, that he refused to take. A Foley catheter was inserted, and his urinary retention relieved. Six hours after arrival in the ED, the patient had sudden onset dyspnea and weakness:

• Atrial flutter with 1:1 AV conduction
• Ventricular rate 246/min
• Left axis deviation
• Non-specific ST abnormality

The patient refused electrical DC cardioversion, and was transferred to the CCU where he received IV amiodarone and the following ECG was taken: 

• Sinus rhythm, 89/min, with occasional premature atrial complexes
• Left anterior fascicular block
• Prolonged QT interval (QT/QTc  = 402/489 msec)