This is a nice teaching strip of a slowing sinus bradycardia that began around 40 bpm, and is slowing. It is a good example of how the sinus node slows down - there is no abrupt change of rates, rather a change with each R-to-R interval. There is also a first-degree AV block, reflecting slowing of conduction in the AV node. The PR interval is slightly variable at .28 sec. to about .32 sec. This is a good strip to begin talking about treatment of bradycardias with beginner students, as there is no second- or third-degee AVB, but the patient is very likely to be symptomatic now, or very soon. Atropine would probably improve this rate in a symptomatic patient, but if there is time, a 12-Lead would be a good idea to rule out acute M.I. Inadvertently raising the rate too much in the injured heart can lead to pump failure, while leaving the patient poorly-perfused in a bradycardia will starve the heart. A transthoracic or temporary IV pacemaker might be a better choice for some patients because of our ability to choose the rate.