An 80-year-old man with paroxysmal atrial fibrillation and symptomatic bradycardia underwent successful pacemaker placement as an outpatient. The patient was restarted on his warfarin therapy and returned home with no complaints. A week later, the patient developed new diffuse chest discomfort that progressed over the ensuing 24 hours to include associated dyspnea and nausea. He presented to the emergency department (ED) for evaluation where he was noted to be afebrile with a blood pressure of 113/66 , heart rate of 95 , and an oxygen saturation of 99% on room air.
Physical examination: He appeared comfortable and in no distress. His cardiac exam was notable only for flat neck veins , an irregularly irregular rhythm , a well-healed pacer site , and NO peripheral edema . Laboratory studies: Laboratory studies revealed a stable hemoglobin level , a negative troponin , and an INR of 2.6…
