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A 62-year-old woman without known cardiac disease presented with a sudden onset of dizziness. The physical examination found the patient in moderate distress with signs of poor perfusion. Her peripheral pulse was 20–30 b.p.m. The electrocardiogram recorded during the symptomatic episode shows sinus rhythm with 2:1 atrioventricular conduction (Figure 1A). The conducted beats have a PR interval of 160 ms followed by a QRS complex with right bundle branch block pattern. The non-conducted P wave is followed by low amplitude, high frequency signal of uncertain origin (Figure 1A, blue arrows).

Level of block: atrioventricular node, infra-Hisian, or intramyocardial?