This 80-year-old patient with a history of COPD had had recurrent admissions over the past few months.  The patient was admitted again on 12/15/08, after he had been discharged the previous day.  Came in with acute on chronic respiratory failure, with CO2 of 57.  The patient was in rapid atrial fibrillation.  RVR with a rapid ventricular response of 160 beats per minute.  The patient was on COPD exacerbation and CHF due to rapid atrial fibrillation.  The patient's heart rate was controlled with IV Cardizem.  Troponin was consistent with non-Q wave MI.  The patient was treated medically transfer to catheterize the patient to evaluate her coronary artery disease.  Echocardiogram showed normal ejection fraction, normal left and right side, but stage 3 restrictive physiology.  There was also prosthetic aortic valve.  The patient was admitted to Intensive Care Unit and was intubated.  Pulmonary was managed by Critical Care, Dr. X.