PAINE #PANCE Pearl – Cardiovascular



64yo male, with a history of HTN, DMII, and hyperlipidemia, is brought in by EMS to the ED with a 2 hour history of lightheadedness and palpitations.  He states both these symptoms seem to fluctuate and nothing seems to make them better or worse when they occur.  He has never had anything like this before.  He denies syncope, chest pain, dyspnea, nausea, vomiting, diaphoresis, or vision changes.



Lisinopril 10mg

Metformin 1000mg

Simvastatin 20mg


Physical Exam

General – NAD, A&Ox3

HEENT – no diaphoresis, no gaze deviation, no facial palsies

CV – irregular, no M/G/R

Pulm – CTA bilaterally

MSK – 5/5 strength throughout

Neuro – CN II-XII grossly intact, MAE


While getting set up for a formal 12 lead EKG, the paramedic hands you the rhythm strips from transport:


What is the diagnosis????


Image result for sick heart yeti


Answer – Sick Sinus Syndrome



SSS is characterized by chronic sinoatrial node dysfunction with chronotropic incompetence and inappropriate heart rate responses to physiologic demands.  Classically, patients have bouts of bradycardia, tachyarrythmias, and sinus pauses or arrests.


Signs and Symptoms

  • fatigue
  • lightheadedness
  • palpitations
  • pre-syncopy and/or syncope



  1. Jensen PN, Gronroos NN, Chen LY. Incidence of and risk factors for sick sinus syndrome in the general population. Journal of the American College of Cardiology. 2014; 64(6):531-8. [pubmed]

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