Diagnosis: Sinus Bradycardia w/ 3rd degree AV block, Right bundle branch block, LAFB, old inf MI.

Discussion: There is no association between the p waves and the QRS complexes, demonstrating complete AV disassociation, allowing the ventricle to beat at what seems to be a junctional rate. There is further disease in the conduction system as is evidenced by the RBBB and LAFB, RBBB is evidenced by the RSR' in V1 w/ Wide S waves in Lead I and V6, LAFB is diagnosed by the fact that the maximal upward deflection in AVL occurrs more that one half box, (0.02sec) before the maximal upward deflection in AVL, plus the negative axis. In LAFB current passes through the ventricle from posterior to anterior in a counterclockwise direction, such that current vector will point in the direction of AVL before AVR.

Also note the inferior Q waves suggesting of an old MI.

This patient most probably is has syncope secondary to his low heart rate due to his av nodal current defects. He could benefit from a ventricular demand pacemaker, he should also probably be worked up for coronary artery disease.