A 55-year-old diabetic, hypertensive man receiving long-term hemodialysis presented to the emergency department with a complaint of two episodes of lightheadedness, the last being on the morning of hospital admission while straining at stool. He denied having lost consciousness at any time. The patient had been dialysis dependent for the last 5 years and had recurrent episodes of arteriovenous graft thrombosis requiring revisions, with recent placement of a right internal jugular hemodialysis catheter 2 weeks ago after removal of a left internal jugular vein hemodialysis catheter. His diabetes and hypertension were poorly controlled, and he had recently been switched from oral medications to insulin. A review of systems did not reveal any history of conduction abnormalities, heart failure symptoms, or previous ischemic events, but was significant for both resting and exertional dyspnea for the last 1 week.