Scenario: An 83-year-old woman with ischemic cardiomyopathy comes in for a routine checkup. She is receiving appropriate medical management with pharmacological agents and has had no acute symptoms.

Controlled atrial fibrillation at 83/min, with left ventricular hypertrophy (LVH)

Atrial fibrillation is present with irregularly irregular ventricular activity in the absence of discrete P waves for every QRS. Although the third QRS complex has what appears to be a P wave in front of it, this pattern is not consistent throughout the strip. The ventricular rate is fewer than 100/min; therefore, the ventricular response is “controlled.” The Q wave in aVL (nearly ≥40-ms duration) suggests a prior myocardial infarction; given the patient’s cardiomyopathy, the contiguous lateral leads, I and V6, also should be evaluated. The amplitude of the S wave in V3 suggests this patient may have...

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