Snapshot A 68-year-old patient presents to the emergency department with acute respiratory distress. In addition to his difficulty breathing, he complains of intermittent palpitations for the past three months. His EKG is shown. Introduction Multiple concurrent atrial pacemakers or re-entrant pathways Usually found in patients with COPD or other structural heart damage Presentation Symptoms may be asymptomatic can present with COPD Physical exam often hypoxic at baseline Evaluation EKG tachycardia distinguishes it from Wandering pacemaker rhythm 3+ distinct P wave morphologies in 1 rhythm strip Differential Atrial flutter with an irregular ventricular response, atrial fibrillation on physical exam, SVT, ventricular tachycardia Treatment Verapamil and/or β-blockers used for rate-control and to suppress atrial pacemakers Treat the underlying condition Prognosis, Prevention, and Complications Prognosis some patients return to baseline state with proper rate control Prevention careful monitoring of all electrolyte disorders including hypokalemia, hypomagnesemia, and drug therapy patient education