Atrial fibrillation with fast ventricular rate in a patient with DCMP with CRT-P

A 56 years old female comes to JIPMER, Pondicherry, India with chief complaints of acute onse palpitation since last two days with dyspnoea of NYHA class III with orthopnea and paroxysmal nocturnal dyspnoea. Patient was a known case of Dilated cardiomyopathy with normal coronary artery with Left bundle branch block with severe left ventricular dysfunction (LVEF 30%). She underwent CRT-P implantation at JIPMER hospital on July 2013. She was on tablet enalapril, carvedilol, lasix, aldactone. During evaluation in the emergency her pulse rate was 140 beats per minute, BP=100/50 mmhg, CVS S1S2 were normal, RS-Bilateral equal air entry, no crepitations.Patient ECG done in the emergency department is shown below.

                                                ECG 1(Click on the image to enlarge it)

Description of the ECG-Heart rate around 140 beats per minute, irregular, No visible P wave seen, left axis deviation seen, QRS complex LBBB morphology, QRS duration 150 msec, Intermittent biventricular pacing spikes are seen, associated QRS complex of LBBB morphology, QRS duration 120 msec so the ecg diagnosis is Irregular, broad complex tachycardia suggestive of  supraventricular tachycardia, so the ecg is suggestive of Atrial fibrillation with fast ventricular rate.

ECG 2 

So the diagnosis of the patient is atrial fibrillation with fast ventricular rate. Patient underwent successful AV nodal ablation at JIPMER hospital for rate control.

Lets discuss how to approach in a patient with Tachycardia

Thank you.