Scenario: The rhythm strip below (leads II and V1) was an alarm for ventricular tachycardia (VT) in a 72-year-old man being treated in the cardiac intensive care unit for an acute exacerbation of heart failure. The patient was intubated and thus unable to report symptoms. His blood pressure was unchanged during the alarm (90/50 mm Hg). The patient has a history of coronary artery disease, heart failure due to ischemic heart disease, and paroxysmal atrial fibrillation. The nurse noted the wide QRS complex in lead II but not V1 and wondered if this was true VT given the wide QRS complex; thus, he printed a rhythm strip with additional electrocardiography (ECG) leads (see next page).

The baseline rhythm is sinus tachycardia with left bundle branch block pattern (ie, P waves present, QRS > 120 milliseconds, deep S wave in V1, and discordant T waves)....

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