Wael M. is a 78-year-old man who is brought to the emergency room after collapsing at the casino. The last thing he recalls before losing consciousness is drawing an ace while sitting at the blackjack table. His past medical history is unremarkable and he is on no medications. On arrival to the ER, his heart rate is 30 bpm with a blood pressure of 80/50 mmHg. He is alert and oriented, but feels lightheaded. His JVP is not elevated, but cannon a-waves are occasionally seen. There are no carotid bruits. The remainder of the physical examination, including a neurological examination, is normal. In the ER, a temporary transvenous pacemaker is inserted via the right internal jugular vein and positioned into the right ventricular apex. The pacemaker is turned on and set to pace at 60 bpm. At this rate, Wael M.'s BP increases to 100/70 mmHg and his light-headedness resolves. The next morning, Wael M. has a dual chamber permanent pacemaker inserted. His 12-lead EKG post implant shows paced ventricular beats with a left bundle branch block pattern.