Elderly Woman Presenting with Hypotension and Tachycardia

An 83-year-old women without known cardiovascular issues presents to the ED after experiencing acute onset palpitations, dyspnea and chest pain while eating dinner. 

On physical exam she is alert but looks fatigued. Vitals show a temperature of 98.6, pulse of 170, BP of 85/46, respiratory rate of 27 and pulse ox of 91% on room air. Her physical exam is significant for regular rapid heart sounds without murmurs, bibasilar pulmonary crackles, elevated jugular veins and trace bilateral ankle edema.

The 12-lead ECG on presentation is shown below:

Question 1: What is the differential diagnosis of this patient’s arrhythmia? 

Question 2: What diagnostic and potentially therapeutic interventions are now indicated?

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