Sade A. is a 54-year-old woman known to have hypertrophic cardiomyopathy. She was diagnosed at age 18 when she had a syncopal episode. She was told to avoid any competitive or physically demanding sports. Her brother was also diagnosed with the same condition. Her echocardiograms have shown increased septal thickness and obstruction to flow at the left ventricular outflow level. She is on metoprolol to decrease the degree of outflow obstruction. She was well until a few weeks prior to consultation when she started to feel her heart racing and felt frequent irregular heartbeats. Since then, her heart rate has been consistently around 110-120 bpm. She has also noticed effort intolerance. She used to be able to walk her dog, but now she becomes short of breath as soon as she reaches an incline and has to slow down. On exam, her heart rate is 105-110 bpm and irregular, blood pressure 118/68 mmHg, JVP is not elevated, she is acyanotic. You can hear crackles at both lung bases, no peripheral edema, precordial exam reveals a sustained apical impulse and a grade 3/6 systolic murmur which increases with the Valsalva maneuver.