Syncope in an Old Lady

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Author(s) A.A.M. Wilde
NHJ edition: 2009:02,077
These Rhythm Puzzles have been published in the Netherlands Heart Journal and are reproduced here under the prevailing creative commons license with permission from the publisher, Bohn Stafleu Van Loghum.
The ECG can be enlarged twice by clicking on the image and it's first enlargement
Puzzle2009 02.jpg

An 83-old-female patient presents to your outpatient clinic with a history of syncope. It has occurred three times in the last few months and there were no specific triggers. She is otherwise feeling well, has no other complaints and does not have any relevant medical history. Physical examination reveals no abnormalities except for a relatively slow heart rate (45 beats/min). Her ECG is presented in figure 1.

What is your diagnosis and what would you consider the most likely cause of her complaints?