Make the Diagnosis: Syncope Stumper

(MedPage Today) -- Case Findings: An 81-year-old man with past medical history of diabetes, hypertension, and coronary artery disease with inferior MI and coronary artery bypass grafting 4 years ago presents for evaluation of syncope. The patient reports 6 recent episodes of syncope between 9 and 3 months ago. Of these, 3 episodes occurred in the evening between 11:00 p.m. and midnight, and involved a prodrome of lightheadedness and flushing, and a postdrome of confusion and nausea. Blood sugar was checked shortly after these episodes and was found to be low. Two episodes occurred in the morning shortly after rising from bed. Neither of these episodes involved prodrome or postdrome. The patient was shaving prior to one episode, and after syncopizing blood sugar was found to be low. After the other episode, blood sugar was in the normal range. The final episode occurred while standing in a parking lot talking to friends, and occurred without prodrome or postdrome. During this episode, the patient experienced a scalp laceration that required sutures. Nuclear perfusion scan demonstrated an ejection fraction of 67%, fixed inferolateral scar, and no evidence of ischemia with no ventricular dimensions. An echocardiogram supported these findings, and showed no valvular disease. A 30-day event monitor demonstrated rare PVCs and PACs, sinus rhythm, sinus bradycardia, and a maximum pause of 2.5 seconds. The ECG is shown in the image below. Which of the following is the appropriate next step for this patient?
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