-Accelerated Junction Rhythm which later REVERTS  to Sinus.

-LAE [Left Atrial Enlargement]

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I think it is focal atrial tachycardia. DC shock may be needed to terminate it then followed by amiodarone as he looks hemodynamically compromised.

Negative P wave in inferior leads. We must rule out,

1. Atrial tachycardia

2, Atypical AVNRT(fast-slow type)

3. PJRT

I think there is an еpisode of unstable AT (5th sinus beat) -  focal atrial tachycardia with activation of coronary sinus (CS), which is transformed through accelerated junctional rhythm (3 complexes) into multifocal tachycardia (3 different P waveforms аt the end of the ECG strip, lead II, the last 3 complexes). Longer ECG recordings are therefore useful.

the rhythm start with low atrial tachycardia then switched to sinus tachycardia 

that is a common issue in worsening heart failure

I think correction of heart failure and its true precipitation would terminate this compensatory rhythm

@Tatiyana Vaikhanskaya, the Interpolated PAC is contributing tO ''3 different''  P waveforms аt the end of the ECG strip, lead II, BUT it does NOT qualify for ''MAT''

Earlier Comment in place;

Rhythm seems to be Accelerating again by the end of the strip and the PRi starts to shorten again, I'm thinking of intermittent     ↓sed SAnode automaticity + ↑SED  AVnode automaticity & normal SA/AV automaticity. Is this patient by any chance on Isuprel? Recent cardiac surgery? Artefact makes me think pt is breathing heavely: Any Pulmonary Disorder??

@Asad, the patient is not on Isuprel, no cardiac surgery, no pulmonary disease. Dilated left heart chambers with severe LV systolic dysfunction. But he was severely dyspnoeic when the EKG was taken.

@Mohammad Awal, Tnx, Its a #GREATCASE.Keep sharing

ECG showing three different P wave morphology and varing PR interval with tachycardia.So rhythm is fitting with multifocal atrial tachycardia .Another possibility may be atrial flutter with 2:1 AV block because heart rate around 150/mint.ECG  also showing poor R wave progression from v1-v4 which is an indirect evidence of myocardial dysfunction.Beta blocker and amiodarone along with other heart failure medication may be useful.Rarely long standing multifocal atrial tachycardia primarily may lead to dilated cardiomyopathy like picture which is called tachycardia induced cardiomyopathy.In that case EP study and RF ablation may be helpful.

Multifocal atrial tachycardia

Atrial Tachycardia

Is this WPW?

This is likely a multifocal atrial tachycardia. If haemodynamically compromised then DC cardioversion is the treatment of choice. If not unstable, then beta blockade or amiodarone may be used.