This 88-year-old woman with a history of pulmonary tuberculosis, severe bullous emphysema, and pulmonary fibrosis was admitted to the intensive care unit with bronchopneumonia and acute respiratory insufficiency requiring intubation:

• Coarse atrial fibrillation with rapid ventricular response (136/min)
• Right bundle branch block 
• Right ventricular hypertrophy

Coarse atrial waves are seen, that in the rhythm strips appear to vary in rate and morphology. In coarse atrial fibrillation, intermittently regular flutter-like waves may frequently be seen, usually for short periods of a few seconds, due to the predominance of a single macro-reentry circuit. While the possibility of coexisting atrial fibrillation and atrial flutter in the same patient is well recognized, the changing pattern of the coarse atrial waves and the irregularly-irregular ventricular response favor the diagnosis of atrial fibrillation.

The diagnostic criteria of RBBB + RVH are present (Right axis deviation + R in V1 15 mm or greater). This patient had severe diffuse pulmonary disease and clinical evidence of pulmonary hypertension.