Clinical History 201

Sixty-six year old gentleman with advanced coronary artery disease and prior coronary artery bypass graft surgery. He has severe left ventricular systolic dysfunction. He now returns for a follow-up cardiac evaluation. He currently complains of fatigue but otherwise feels well. Medications at the time of this electrocardiogram included digoxin, furosemide, isosorbide mononitrate and amiodarone.
Comment on this ECG ?