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  A 63 year old male with a long standing history of hypertension, hyperlipidemia and long standing tobacco abuse presents to the emergency room with a four hour complaint of severe chest pain, nausea, dyspnea and diaphoresis.
On examination, the patient is in moderate distress. His skin is warm and dry. BP is 95/60 mm Hg and pulse is regular at 70/min. Neck veins are 4 cm above the clavicle at 30 degrees but there is no abdomino-jugular reflux There is an S4 gallop at the apex together with a grade 2/6 systolic ejection murmur. Lungs are clear and the peripheral pulses are normal. His ECG is shown, below.
The patient received sublingual NTG, 3 mg of intravenous morphine sulfate, and ASA gr. V. Two minutes later, the patient's BP drops to 70/30 mm Hg. Pulse is 60/min.

Which of the following represents the most likely cause for his hypotension:

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