A 79 year old female wit history of CAD, diastolic CHF, HTN, Hyperlipidemia, previous smoking history, and atrial fibrillation who presents for direct admission from home for progressive shortness of breath. Patient denies recent palpitations, and reports that she has been compliant with all medications. She admits to recent fatigue and 2 pillow orthopnea which has been present for months.  Patient underwent cardioversion and became hypotensive with a junctional rhythm requiring intubation.  She was placed on dobutamine.  Off of dobutamine, cardiac monitoring demonstrated a long QTc and an atrial escape rhythm.