Atrial fibrillation? Multifocal Atrial Tachycardia? Don ' t look at computer read until AFTER you interpret!

This 60-something with h/o COPD and HFrEF (EF 25%) presented with SOB and chest pain.Here is the ECG:What do you think?Computer interpretation is below.Here is the computer interpretation:ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE WITH ABERRANT CONDUCTION OR VENTRICULAR PREMATURE COMPLEXESLEFT AXIS DEVIATION [QRS AXIS beyone -30]NONSPECIFIC ST and T-WAVE ABNORMALITYThe over-reading physician confirmed this diagnosis, which is incorrect.  It isnot atrial fibrillation.The rhythm is indeed irregularly irregular, so atrial fibrillation must be considered.There are 5 other rhythms that areirregularly irregular, though atrial fibrillation is by far the most common:1. Multifocal Atrial Tachycardia2. Sinus with multifocal PACs3. Sinus with multifocal PVCs4. Polymorphic VT (which is always wide complex, so does not apply here)5. Atrial fibrillation with WPW (which is also wide complex)This is NOT atrial fibrillation, as demonstrated in this annotated version:The rate is 120One should look for sinus beats by looking for an up-down P-wave in V1.We findtwo (black arrow, and then another 2 beats later)Then confirm that it is a sinus beat by going directly down to lead II across the bottom.We find a corresponding typical lead II P-wave, confirming sinus rhythm (black arrow at bottom).Then look for other similar P-waves (see red arrows).Then notice that there areseveral other P-wave morphologies, and that several come early such that the QRS is aberrant, with an...

Source: Dr. Smith's ECG Blog - January 4, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs