Case report

A 54 year old white man presented with nausea, dizziness, and collapse after an episode of severe angina 10 hours previously. He had been free of pain for 8 hours but was bradycardic and hypotensive and had severe pulmonary oedema. He had no features suggestive of ongoing infection. Maintenance treatment for his angina was bisoprolol 5 mg once daily, slow release diltiazem 180 mg twice daily, isosorbide mononitrate 40 mg three times a day, nicorandil 10 mg twice daily, frusemide 40 mg once daily, simvastatin 20 mg once daily, fluoxetine 40 mg once daily, and aspirin 75 mg once daily. He was known to have severe triple vessel coronary artery disease and poor left ventricular function. Electrocardiography indicated a sinus bradycardia with new first degree heart block (PR interval 300 milliseconds), pre-existing left bundle branch block, and no new changes in the ST segments or T waves suggestive of an acute myocardial infarction.1 Despite treatment for cardiogenic …