A 66-year-old man with severe COPD exacerbation has an irregular tachycardia at 120 bpm. ECG shows at least three distinct P wave morphologies with varying PP, PR, and RR intervals. What is the most appropriate initial management?

• A Immediate synchronized cardioversion
• B Catheter ablation of the pulmonary veins
• C IV amiodarone loading dose
• D Treat the underlying pulmonary disease; add a calcium channel blocker if rate control is needed ✓

Explanation

Multifocal atrial tachycardia is defined by three or more P wave morphologies with irregular intervals, and it occurs almost exclusively in patients with advanced lung disease. Therapy targets the underlying condition: oxygenation, bronchodilation, and treating infection. If rate control is required, verapamil or diltiazem is used cautiously. Beta blockers are poorly tolerated in severe COPD, cardioversion does not work because multiple atrial foci re-emerge, and ablation is ineffective since there is no single driver.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.