Question

A 67-year-old male was referred to the outpatient clinic of our hospital with crescendo angina pectoris since one month. He had been diagnosed with atrial fibrillation in a general practice three days earlier and treatment with metoprolol and apixaban was initiated. He was an otherwise healthy and active cyclist who smoked a cigar on occasion. There were no other risk factors for coronary artery disease. An echocardiogram performed five years ago because of persistent bradycardia, was normal.

Physical and laboratory examination on admission did not reveal any abnormalities. His initial troponin I level was 11 ng/l, with repeat troponin I concentration found at 14 ng/l (normal range 0–10 ng/l). The resting electrocardiogram at presentation is shown in Figs. 1 and 2.

Fig. 1
figure 1

Electrocardiogram on admission in an asymptomatic patient

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Fig. 2
figure 2

The same electrocardiogram displayed in a 12-lead rhythm strip

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What is your diagnosis based on the electrocardiographic findings?

What would be your next step or treatment?

Answer

You will find the answer elsewhere in this issue.