A 34-year-old woman is evaluated prior to surgical repair of a torn medial meniscus of the right knee. Her knee pain began about two years ago, was gradual in onset, and was not a result of injury or antecedent events. During the last two weeks, her pain has become significantly more severe. She describes it as “throbbing,” “sharp,” and “constant,” rating it 10 out of 10 on a pain scale. The pain worsens with any activity, including walking or bending, and has not responded to NSAIDs or oxycodone. MRI confirmed a “bucket-handle” tear of the medial meniscus of the right knee.

Medical history is remarkable for anxiety disorder, depression, type 2 diabetes mellitus, hypertension, and hypercholesterolemia. There is no prior surgical history. The patient’s family history is significant for diabetes and hypertension. Her mother died suddenly from a “heart condition” at age 40.

The patient denies a history of smoking or recreational drug use, but she does have a history of alcohol abuse. Her last use of alcohol was six months ago. Symptom review reveals four episodes of syncope during the last year, which were attributed to her anxiety disorder by her mental health care provider. The remainder of the systems review is noncontributory.

The patient has no drug allergies. Her current medication list includes atenolol (100 mg/d), lisinopril (40 mg bid), atorvastatin (80 mg/d), metformin (1,000 mg in the morning and 500 mg at night), levetiracetam (1,000 mg bid), and mirtazapine (45 mg at bedtime).

Preoperative laboratory data are within normal limits, and the chest x-ray is normal. What is your interpretation of this ECG—and is there anything in the patient’s history to warrant concern?