This is an electrocardiogram from a 77 year old man with a history of coronary artery disease. He was taking Monopril, metoprolol, ASA and Hytrin. The cardiogram shows sinus rhythm with a marked first degree heart block ( about 360ms). There is also a poor R wave progression across the precordial leads and a Q wave in V2 suggestive of a previous anterior wall infarction. The QRS also has a left axis deviation best described as a left anterior hemi-block.