ECG of the Month: 67-Year-Old Female with History of Ischemic Cardiomyopathy and Paroxysmal AF Presents with Episodic Palpitations and SOB

A 67-year-old female with a history of ischemic cardiomyopathy and paroxysmal atrial fibrillation presents with episodic palpitations and shortness of breath. Echocardiogram demonstrates stable left ventricular ejection fraction at 35-40% and severely enlarged left atrium. Current medications included metoprolol, digoxin, furosemide, simvastatin, rivaroxaban and aspirin. A Holter monitor is completed to evaluate her symptoms. The following tracing was recorded (Figure 1).

Figure 1

Figure 1

Which of the following is the most appropriate next step in her management?

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