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A 63-year-old woman presented to the emergency department with a 3-h history of dizziness and palpitations, which awoke her from sleep. She had had one similar episode a year earlier that resolved spontaneously after 1 h and for which she did not seek medical attention. She had no significant past medical history and was not taking any regular medications.
At the time of examination the patient was asymptomatic and no longer complaining of palpitations. Examination was unremarkable except for a resting tachycardia of 130 beats per minute (bpm), there were no signs of cardiovascular compromise. A 12-lead ECG showed a regular narrow complex tachycardia with either P or flutter waves. The patient was placed on continuous ECG monitoring and it was noted that the heart rate remained fixed at 130 bpm. The probability of atrial flutter at a rate of 260 and a 2 : 1 block was considered.
The valsalva manoeuvre was performed to attempt to differentiate between atrial flutter and sinus tachycardia but was unsuccessful.
After auscultation of her right carotid artery and hearing no bruits, carotid sinus massage (CSM) was performed by firmly massaging the right common carotid artery in a longitudinal plane for 10 s.