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Textbook of Clinical Electrocardiography for Postgraduates, Residents and Practicing Physicians
SN Chugh
SECTION 1: PHYSIOLOGICAL MECHANISMS GOVERNING ELECTROCARDIOGRAPHIC DEFLECTIONS
1:
Fundamentals of Electrocardiography
ELECTROCARDIOGRAM—AN INTRODUCTION
Definition
Electrical Activity
Usefulness of Electrocardiogram (ECG)
What does an ECG Complex Indicate?
What does an ECG Complex Record?
EINTHOVEN THEORY OF ELECTRICAL ACTIVITY
ANATOMY AND PHYSIOLOGY OF CONDUCTION TISSUES OF THE HEART (FIG. 1.1)
APPLIED PHYSIOLOGY
P Wave
QRS Complex
MODES OF ACTIVATION OF THE HEART (ATRIA AND VENTRICLES, FIGS 1.2A AND B)
2:
The Electrode and the Lead System
ELECTRODES
LEAD SYSTEM
Classification of Lead System
Limb Lead System
Chest Electrodes and Chest Leads
ARBITRARY ORIENTATION OF DIFFERENT LEADS
CONTINUOUS MONITORING SYSTEM USED IN CORONARY CARE UNIT (CCU)
A. Three Electrodes Monitoring System
B. Five Electrodes Monitoring System
SPECIAL OR UNCONVENTIONAL LEADS FOR RECORDING ATRIAL ACTIVITY FROM BACK OF THE HEART
3:
Action Potentials and Waveforms
CHARGED OR POLARIZED OR RESTING MEMBRANE
GENERATION OF ACTION POTENTIAL IN PACEMAKER CELLS
Clinical Importance of Action Potential
Recording of Depolarization and Repolarization as Waveforms
RECORDING OF DEPOLARIZATION AND REPOLARIZATION AS WAVEFORMS (P-QRS-T COMPLEX) ON ECG
ATRIAL DEPOLARIZATION WAVE (ATRIAL COMPLEX—P WAVE)
Genesis of P Wave
VENTRICULAR ACTIVATION COMPLEX (DEPOLARIZATION)
Genesis of QRS Complex
Types of QRS Complex (Fig. 3.12)
Right Ventricular Epicardial Complex
Left Ventricular Epicardial Complex
Cavitary Pattern and the Cavitary Lead
INTRINSIC OR INTRINSICOID DEFLECTIONS
PHYSIOLOGY OF R WAVE PROGRESSION
Clinical Significance
4:
The Cardiac Vector and the Electrical Axis
ELECTRICAL FIELD OF THE HEART
AXIAL REFERENCE SYSTEMS
Triaxial Reference Systems
Standard Limb Leads Triaxial Reference System
Unipolar Limb Lead Triaxial Reference System
Hexaxial Reference System
How to Label the Hexaxial System?
VENTRICULAR DEPOLARIZATION, INSTANTANEOUS QRS VECTORS AND THE MEAN MANIFEST ELECTRICAL AXIS
Ventricular Depolarization, Instantaneous QRS Vectors
Mean Manifest Electrical Axis
Determination of Mean Manifest Electrical Axis on Hexaxial Reference System (Frontal Plane)
Determination of Frontal Plane QRS Axis with the Help of an Electrocardiogram
Method
Bisector Method
Method
Note
Adjustment Method or Approximation Method
Other Methods for Determination of Axis
Quadrant Method
Visual Impression Method
AXIS DEVIATION
Causes of Axis Deviation and its Mechanism
Explanation
Calculation of QRS Vector on Horizontal Plane
Calculation of QRS Vector on Both Frontal and Horizontal Plane
Mean QRS Vector of the Given Electrocardiogram
T Wave Axis and QRS-T Axes Angle
Significance of QRS-T Angle
Determination of P Wave Axis
ST Segment Axis
Abnormality of ST Segment Axis and Associated Conditions
ABNORMAL P WAVE AXIS AND ASSOCIATED CLINICAL CONDITIONS
5:
The Electrical Rotation of the Heart
POSITIONS OF THE HEART
Rotation of the Heart on Anteroposterior Axis
Various Positions of the Heart
Rotation Around Horizontal or Oblique Axis
Clockwise Rotation
Counterclockwise Rotation
EFFECT OF DEEP RESPIRATION ON THE ROTATIONAL PATTERNS
SECTION 2: THE ELECTROCARDIOGRAM
6:
Normal Electrocardiogram
ELECTROCARDIOGRAPHIC (ECG) PAPER (FIG. 6.1)
Speed of the Paper
Standardization of ECG
Variations during Standardization
HEART RATE
Calculation of Heart Rate on ECG
NATURAL PACEMAKERS AND HEART RATES
Subsidiary Pacemakers
PREREQUISITE FOR GOOD ELECTROCARDIOGRAM RECORDING
NORMAL ELECTROCARDIOGRAM IN ADULTS
NORMAL COMPONENTS OF AN ECG COMPLEX (Fig. 6.11)
Normal P Wave
P Wave Characteristics
Normal QRS-T Complex/Deflection
Characteristics of Normal QRS Complex
Factor Governing QRS Complex
Progression of R Wave in Precordial Leads
Abnormalities of R Wave Progression
QRS Deflection with their Nomenclature (Fig. 6.16)
Normal T Wave (Fig. 6.17)
Normal U Wave (Fig. 6.17)
Normal QRS-T Angle (Fig. 6.18)
NORMAL ELECTROCARDIOGRAPHIC INTERVALS
P-R Interval (Figs 6.19 and 6.20)
QRS Interval (Fig. 6.21)
QT Interval (Figs 6.24 and 6.25A to C)
Relation of Heart Rate (R-R Interval) to QT and QTc (Tables 6.2 and 6.3)
QT Dispersion (QTd)
Clinical Conditions Associated with Wide QTd Interval
Clinical Significance
QU Interval
P-P Interval (Fig. 6.26)
R-R Interval (Fig. 6.26)
JT Interval
NORMAL SEGMENTS AND JUNCTIONS ON ECG
PR Segment
ST Segment
Segment
R-S Junction
VOLTAGE MEASUREMENT
ELECTROCARDIOGRAM IN INFANTS (FIG. 6.30)
ELECTROCARDIOGRAM IN CHILDREN (FIG. 6.31)
7:
Normal Electrocardiographic Variants in Adults
NORMAL ELECTROCARDIOGRAPHIC VARIANTS IN ADULTS—GENERAL ASPECTS
CONDITIONS ASSOCIATED WITH WELL RECOGNIZED ELECTROCARDIOGRAPHIC VARIANTS
Juvenile Pattern in Adults (Fig. 7.5)
Hyperventilation and Anxiety States (Fig. 7.6)
Effect of Heavy Carbohydrate Meal (Fig. 7.7)
The Athlete's Heart (Fig. 7.8)
Early Repolarization Syndrome (Fig 7.9)
Specific ECG Abnormalities in Normal Persons
SECTION 3: CHAMBER HYPERTROPHY OR ENLARGEMENT
8:
Atrial Hypertrophy/Enlargement
ANATOMY AND ELECTROPHYSIOLOGY OF HUMAN HEART
CHAMBER ENLARGEMENT
P Wave Abnormalities
ATRIAL HYPERTROPHY AND ENLARGEMENT
Etiology
Electrocardiographic Criteria
LEFT ATRIAL HYPERTROPHY OR ENLARGEMENT
Causes
The Electrocardiogram (Figs 8.5 and 8.6)
Clinical Significance
RIGHT ATRIAL HYPERTROPHY OR ENLARGEMENT (FIG. 8.7)
Causes
Electrocardiogram (Figs 8.8 to 8.10)
COMBINED RIGHT AND LEFT ATRIAL HYPERTROPHY (BIATRIAL HYPERTROPHY)
Etiology
Electrocardiogram (Figs 8.11 and 8.12)
Other Abnormalities of P Waves
P Wave Characteristics in Retrograde (Ventriculoatrial) Conduction
Explanation (Figs 8.14A and B)
REVIEW AT GLANCE
Atrial Hypertrophy or Enlargement on ECG
9:
Ventricular Hypertrophy/Enlargement
LEFT VENTRICULAR HYPERTROPHY (LVH)
Electrocardiographic Criteria
Left Ventricular Hypertrophy Patterns
1. Abnormalities of QRS
2. ST-T Changes
Electrocardiogram
1. Left Ventricular Hypertrophy with Horizontal Heart
Electrocardiogram (Figs 9.7 to 9.9)
2. Left Ventricular Hypertrophy with Vertical Heart Electrocardiogram (Fig. 9.11)
Effect of Rotation on Left Ventricular Hypertrophy
Left Ventricular Strain (Fig. 9.13)
REVIEW AT GLANCE
Left Ventricular Hypertrophy
RIGHT VENTRICULAR HYPERTROPHY (RVH)
Etiology
Electrocardiographic Criteria
Mechanisms
Electrocardiographic Patterns
1. Abnormalities of QRS
2. ST-T, U Changes
3. Associated Right Atrial Hypertrophy
Right Ventricular Strain Pattern (Fig. 9.18)
BIVENTRICULAR (COMBINED RIGHT AND LEFT VENTRICLES) HYPERTROPHY
Etiology
Electrocardiographic Patterns
Mechanisms
Electrocardiogram (Figs 9.19 and 9.20)
SECTION 4: CONDUCTION DEFECTS
10:
Intracardiac Conduction Defects
BASIC CONCEPTS OF CONDUCTION
A. Formation of Impulse in SA Node
B. Atrial Depolarization with Formation of P Wave
C. Conduction through AV Node
D. Ventricular Depolarization (QRS Complex)
E. Conduction Block
F. Re-entry Mechanism
The Graphic Representation of Intracardiac Conduction
11:
Sinus Node Dysfunction
SINUS NODE DYSFUNCTION AND STRUCTURAL NODAL DISEASE
Physiology of Sinus Node
Disorders of SA Node
Sinoatrial or Sinus Arrest or Sinus Pause
Electrocardiogram in Sinus Pauses or Arrest (Figs 11.1A and B)
SINOATRIAL BLOCKS (SA BLOCKS)
Causes
Types
Electrocardiogram in Second Degree SA Block (Fig. 11.3)
SICK SINUS (LAZY SINUS, UNSTABLE SINUS) SYNDROME—THE STRUCTURAL NODAL DISEASE
The Electrocardiographic Manifestations of Sick Sinus Syndrome
Diagnosis
Provocative Tests
HYPERSENSITIVE CAROTID SINUS SYNDROME
The Electrocardiographic Manifestations
12:
Atrioventricular (AV) Blocks
INCOMPLETE AV BLOCKS
A. First Degree AV Block
His Bundle Electrocardiography
The Electrocardiogram in First Degree AV Block (Figs 12.3 and 12.4)
B. Second Degree AV Block
Types
The Electrocardiogram (Figs 12.6A and B)
The Electrocardiogram in Mobitz Type II AV Block (Fig. 12.7)
COMPLETE (THIRD DEGREE) AV BLOCK
Definition
The Electrocardiogram
CLINICAL SIGNIFICANCE OF SECOND DEGREE AV BLOCK AND COMPLETE AV BLOCK
Stokes-Adams Attacks
HIGH GRADE AV BLOCK (FIG. 12.15)
DIAGNOSING AV BLOCKS AT GLANCE
Results and Conclusions
13:
Bundle Branch Blocks
DISORDERS OF INTRAVENTRICULAR CONDUCTION
BUNDLE BRANCH BLOCKS
Terminology Used
Mechanisms
Clinical Significance
Electrocardiographic Criteria
RIGHT BUNDLE BRANCH BLOCK PATTERN
Mechanisms
Electrocardiogram (Figs 13.4A and B)
Incomplete Right Bundle Branch Block Pattern (Fig. 13.5)
REVIEW AT A GLANCE
RIGHT BUNDLE BRANCH BLOCK WITH LEFT VENTRICULAR HYPERTROPHY (FIG. 13.6)
INTERMITTENT RIGHT BUNDLE BRANCH BLOCK (FIG. 13.7)
RIGHT BUNDLE BRANCH BLOCK WITH RIGHT VENTRICULAR HYPERTROPHY
Right Bundle Branch Block with Persistent ST Segment Elevation (Brugada Syndrome)
Clinical Significance
Electrocardiogram (Figs 13.9A to C)
Diagnosis and Treatment
Normal rSr′ Complexes in V1–A Normal Variant (Figs 13.9A to C)
LEFT BUNDLE BRANCH BLOCK (LBBB) PATTERN
Complete Left Bundle Branch Block Pattern
Mechanisms (Figs 13.11A and B)
QRS complex
Electrocardiogram (Fig. 13.12)
The Standard and Extremities Leads (I, II, III, aVR, aVL and aVF)
Effect of Deep Respiration on LBBB
Incomplete Left Bundle Branch Block Pattern
Mechanisms
The Electrocardiogram (Fig. 13.13)
LEFT BUNDLE BRANCH WITH LEFT ANTERIOR FASCICULAR BLOCK (FIG. 13.14)
LEFT BUNDLE BRANCH BLOCK WITH LEFT POSTERIOR FASCICULAR BLOCK (FIG. 13.15)
LEFT BUNDLE BRANCH BLOCK WITH LEFT VENTRICULAR HYPERTROPHY (Fig. 13.17)
REVIEW AT GLANCE
ALTERNATING RIGHT AND LEFT BUNDLE BRANCH BLOCK (INTERMITTENT BILATERAL BUNDLE BRANCH BLOCK)
MASQUERADING BUNDLE BRANCH BLOCK
BUNDLE BRANCH BLOCK ALTERNANS
NONSPECIFIC OR INDETERMINATE INTRAVENTRICULAR CONDUCTION DEFECT (FIG. 13.19)
14:
The Fascicular Blocks or Hemiblocks
FASCICULAR BLOCKS
Definition
Applied Anatomy and Physiology
THE LEFT ANTERIOR FASCICULAR BLOCK (LEFT ANTERIOR HEMIBLOCK)
Mechanisms
Electrocardiogram (Fig. 14.3)
Clinical Significance of Left Anterior Fascicular Block
LEFT ANTERIOR FASCICULAR OR HEMIBLOCK (LAH) BLOCK WITH LEFT VENTRICULAR HYPERTROPHY (FIG. 14.4)
LEFT POSTERIOR FASCICULAR BLOCK OR LEFT POSTERIOR HEMIBLOCK (LPH)
Electrocardiogram (Figs 14.6A and B)
Clinical Significance
LEFT SEPTAL FASCICULAR BLOCK
PERI-INFARCTION BLOCK
REVIEW AT A GLANCE
COMBINED FASCICULAR BLOCKS
BIFASCICULAR BLOCKS
Etiology
Clinical Significance
1. Right Bundle Branch Block with Left Anterior Fascicular Block (Figs 14.7A and B)
2. Right Bundle Branch Block and Left Posterior Fascicular Block
3. Right Bundle Branch Block (RBBB) with Prolonged AV Conduction
TRIFASCICULAR BLOCK (FIGS 14.9A AND B)
15:
The SI, SII, SIII Syndrome
SECTION 5: STRESS ELECTROCARDIOGRAPHY
16:
Stress Electrocardiography
EXERCISE ELECTROCARDIOGRAPHY
Introduction
Basis of Exercise Test
Indications of Exercise Tests
To Evaluate the Coronary Artery Disease in Symptomatic Patients
For Screening of Asymptomatic Patients
Severity of Coronary Artery Disease
To Test Effectiveness of Treatment
Evaluation of Symptoms
Arrhythmias Analysis
Left Ventricular Functional Assessment
Prognosis in Coronary Artery Disease
To Study Exercise Capacity in Valvular Heart Disease
Evaluation of Congenital Heart Disease
Safety and Risks of Exercise Testing
Standardized Methods for Exercise Testing
Methods
Master's Two Steps Exercise Test
Bicycle Ergometer
Treadmill Test (Figs 16.1A and B)
Bruce Protocol
Nonstandardized Methods
Preparation of the Patient
Lead System Employed
Post-test Evaluation
Sensitivity and the Specificity of Exercise Testing
Techniques
End Points for Termination of Stress Test
Electrocardiographic Manifestations of Stress Testing and their Interpretation
ECG Patterns and their Significance
ST Segment Changes
T Wave Changes
U Wave Changes
QRS Complex Changes
Intraventricular Conduction Changes
Q-T Interval
Rhythm Disturbances (Exercise Induced Arrhythmias)
Post-extrasystolic T Wave Change (Poor Man's Exercise Test)
Significance of the Associated Phenomenon
Heart Rate
Level of Exercise to Produce ECG Changes
3. Time Course of Abnormal ECG Changes
Nonspecific Abnormalities and Exercise Test
Adverse Prognostic Factors on Exercise Testing
PHARMACOLOGICAL METHODS OF STRESS TESTING
Pharmacological Agents and their Actions
SECTION 6: AMBULATORY ELECTROCARDIOGRAPHIC RECORDING
17:
Continuous Ambulatory Electrocardiographic Recording
CONTINUOUS AMBULATORY (HOLTER) MONITORING
Recording Systems
Continuous Recorders
Event Recorders
Microcomputers (Digital Recording System)
Duration of Recording
Lead System (Fig. 17.1)
Indications
Detection of an Arrhythmia (Figs 17.2 to 17.4)
Assessment of Heart Rate Variability (R-R Interval Characteristics)
Detection of Myocardial Ischemia
Patient's Diary
Analysis of Ambulatory ECG Recording (Holter Monitoring)
Limitations of Ambulatory Electrocardiography in Evaluation of ST Segments and T Waves
SUPERIORITY OF AMBULATORY ELECTROCARDIOGRAPHY OVER EXERCISE TESTING
Methods of Analysis of Ambulatory Electrocardiographic Recording
Artifacts and Errors
SECTION 7: CORONARY ARTERY DISEASE
18:
Myocardial Ischemia
INTRODUCTION
Electrocardiographic Manifestations
Abnormalities of ST Segment
Clinical Significance of ST Segment Depression
PSEUDODEPRESSION AND PSEUDOELEVATION OF ST SEGMENT VS TRUE (ISCHEMIC) ST DEPRESSION AND ELEVATION
Abnormalities of T wave in Myocardial Ischemia
Primary T Wave Abnormalities
Secondary T wave Changes
The Abnormalities of U Wave
The QRS-T Angle
ACUTE VERSUS CHRONIC CHANGE
ANGINA IN A PATIENT WITH INFARCTION
NONSPECIFIC ST SEGMENT AND T WAVE CHANGES
CLINICAL AND ELECTROCARDIOGRAPHIC CORRELATION IN ANGINA PECTORIS
VARIANT ANGINA (PRINZMETAL'S ANGINA) SYNDROME
Electrocardiogram
1. Elevation of ST Segment (Figs 18.15 and 18.16)
Clinical Significance
2. Abnormalities of the T Wave
3. Inversion of the U Wave
4. Abnormalities of the QRS Complex
5. Complex Ventricular Arrhythmias (Fig. 18.20)
6. Atrioventricular Block and Intraventricular Conduction Defects
ASYMPTOMATIC ELECTROCARDIOGRAPHIC ABNORMALITIES
19:
Myocardial Infarction
INTRODUCTION
Electrocardiographic Characteristics
Mechanisms of Electrocardiographic Patterns
1. QRS Complex Abnormalities and Their Pathogenesis
QS Complex
Qr or QR Complex
Loss of R Wave Amplitude
2. ST Segment Changes
Explanation on the Basis of the Electrophysiology of Normal and Excited Cardiac Cell
3. T Wave Changes
4. U Wave Changes
HYPERACUTE MYOCARDIAL INFARCTION
Electrocardiogram (Figs 19.11 and 19.12)
Clinical Significance
EVOLUTION OF ACUTE MYOCARDIAL INFARCTION
SUBTLE, ATYPICAL OR NONSPECIFIC PATTERN OF INFARCTION
Serial ECGs and its Significance during Myocardial Infarction
Resolution of ST Segment Elevation on ECG Following Thrombolysis
CHRONIC ESTABLISHED CHANGES
Old Infarction
Significance of Q Wave in Lead III
Persistent ST Elevation (Read Ventricular Aneurysm Towards the End of Chapter)
LOCALIZATION OF MYOCARDIAL INFARCTION BY ELECTROCARDIOGRAPHIC PATTERNS
INFARCTION OF LEFT VENTRICLE
Anterior Left Ventricular Infarction
Inferior Wall Infarction (Figs 19.29A and B)
C. Inferolateral Infarction (Fig. 19.30)
D. Posterior Wall Myocardial Infarction (Figs 19.31 and 19.32)
E. Inferoposterolateral Myocardial Infarction (Figs 19.33 and 19.34)
F. Nontransmural Myocardial Infarction (Fig. 19.35)
Clinical Significance
Infarction at Combined Locations or Multiple Infarctions (Figs 19.36 to 19.38)
Value of Electrocardiography in Localizing the Site of Coronary Artery Occlusion
Inferior Wall Infarction and Site of Coronary Artery Occlusion
Differential Electrocardiographic Diagnosis of Myocardial Infarction
1. Normal Individuals
2. Left Ventricular Hypertrophy (LVH)
3. Hypertrophic Cardiomyopathy
4. Chronic Cor Pulmonale (Chronic Obstructive Pulmonary Disease with Right Ventricular Hypertrophy)
5. Left Anterior Hemiblock
RIGHT VENTRICULAR INFARCTION
Electrocardiographic Pattern (Figs 19.44A and B)
Diagnostic Clues to Right Ventricular Infarction
SUBENDOCARDIAL INFARCTION (FIG. 19.45)
INTERVENTRICULAR SEPTAL INFARCTION
ATRIAL INFARCTION
Sensitivity and Specificity of ECG in Diagnosing Myocardial Infarction
MYOCARDIAL INFARCTION WITH CONDUCTION DISTURBANCE
Myocardial Infarction with Bundle Branch Blocks
1. Right Bundle Branch Block with Myocardial Infarction (Fig. 19.48)
2. Left Bundle Branch Block (LBBB) with Myocardial Infarction (Figs 19.49A and B)
Clinical Significance
3. Fascicular Blocks
Peri-infarction Block (Figs 19.53 and 19.54)
4. Rhythm Disturbance (Figs 19.55A to E)
QT Dispersion and Arrhythmias in Coronary Artery Disease
VENTRICULAR ANEURYSM (Figs 19.56 and 19.57)
SECTION 8: CONGENITAL AND HEREDOFAMILIAL DISORDERS
20:
Congenital Heart Disease
CONGENITAL PULMONARY STENOSIS WITH INTACT SEPTUM
Hemodynamic Alterations
Electrocardiogram (Fig. 20.1)
PRIMARY PULMONARY HYPERTENSION
Hemodynamic Alterations
Electrocardiogram
ATRIAL SEPTAL DEFECT (ASD)
Types of Defects
Hemodynamic Alterations
Ostium Secundum Type of ASD
Ostium Primum Type of ASD
Electrocardiogram
Ostium Secundum Defect (Figs 20.4 and 20.5)
Ostium Primum Defect (Fig. 20.6)
Common Atrioventricular Canal (Fig. 20.7)
Sinus Venosus Defect
ATRIAL SEPTAL DEFECT WITH REVERSED SHUNT—THE EISENMENGER'S SYNDROME
Electrocardiogram
Ostium Secundum Defect with Pulmonary Hypertension (Fig. 20.8)
Ostium Primum Defect with Pulmonary Hypertension
COMMON ATRIUM
Electrocardiogram
VENTRICULAR SEPTAL DEFECT (VSD)
The Hemodynamic Alterations and the Electrocardiogram
MALPOSITION AND MALFORMATION OF THE HEART
DEXTROCARDIA (TRUE OR MIRROR IMAGE VERSUS TECHNICAL)
True Dextrocardia
Electrocardiogram (Fig. 20.14B)
Technical Dextrocardia
Electrocardiogram (Figs 20.15A and B)
PATENT DUCTUS ARTERIOSUS (PDA)
Hemodynamic Alterations
Electrocardiogram (Figs 20.16 to 20.18)
CORRECTED TRANSPOSITION OF GREAT VESSELS (FIG. 20.19)
Hemodynamic Alterations
Electrocardiogram (Figs 20.19B and 20.20)
TETRALOGY OF FALLOT
Hemodynamic Alterations
Electrocardiogram (Fig. 20.21)
PENTALOGY OF FALLOT
Hemodynamic Alterations
Electrocardiogram
TRIOLOGY OF FALLOT
Hemodynamic Alterations
Electrocardiogram
EBSTEIN'S ANOMALY
Electrocardiogram (Fig. 20.22)
P Wave Abnormalities
First Degree AV Block
QRS Abnormalities
Accelerated Conduction
T Wave Changes
Arrhythmias
PERSISTENT TRUNCUS ARTERIOSUS
Hemodynamic Alterations
Electrocardiogram (Fig. 20.24)
AORTOPULMONARY COMMUNICATION (WINDOW)
Hemodynamic Alterations
Electrocardiogram
TRICUSPID ATRESIA
Hemodynamic Alterations
Electrocardiogram (Fig. 20.25)
CONGENITAL AORTIC STENOSIS
Hemodynamic Alterations
Electrocardiogram (Fig. 20.26)
21:
Heredofamilial Prolonged Q-T Syndromes
ACQUIRED PROLONGED Q-T SYNDROME
CLINICAL SIGNIFICANCE
22:
Accelerated Conduction or Pre-excitation
WOLFF-PARKINSON-WHITE (WPW) SYNDROME
Electrocardiographic Pattern—Bundle of Kent Conduction
Mechanisms of Pathogenesis
Diagnostic Clues to Classic WPW Syndrome
Variations in ECG Pattern of WPW Type of Conduction
1. Short P-R Interval with Wide QRS and Shortened P-J Interval (Atrioventricular Conduction) (Figs 22.3A and B)
2. Short P-R Interval, Normal QRS Complex and Short P-J Interval (Atrionodal or Atrio-His Conduction) (Fig. 22.3C)
Rosenbaum Classification of WPW Syndrome
Various Accessory Pathways
Decision Making Leads and Parameters in Localization of an Accessory Tract (Fig. 22.7)
Intermittent WPW Syndrome (Fig. 22.9)
Complications
1. Reciprocating Rhythm and Tachycardia (Read Chapter 36)
2. Atrial Fibrillation in WPW Syndrome (Fig. 22.10)
Differential Diagnosis of WPW Syndrome on ECG
WPW VARIANTS
1. WPW Syndrome with Normal P-R Interval (Mahaim Fibers Pre-excitation)
2. The Lown-Ganong-Levine (LGL) Syndrome (James Bundle Pre-excitation) or Atrio-Hisian Conduction
Summary
23:
Hypertrophic Cardiomyopathy
SECTION 9: ACQUIRED HEART DISEASE
24:
Rheumatic Heart Disease
ACUTE RHEUMATIC CARDITIS (FIG. 24.1)
Electrocardiogram
CHRONIC RHEUMATIC VALVULAR HEART DISEASE
Mitral Stenosis (MS)
Hemodynamic Alterations
Electrocardiogram (Fig. 24.2)
Mitral Regurgitation
Hemodynamic Alterations
Causes
Electrocardiogram (Figs 24.4A and B)
Combined Mitral Stenosis and Regurgitation (MS and MR)
Electrocardiogram (Fig. 24.6)
Aortic Stenosis (Read Congenital Aortic Stenosis in Chapter 20)
Hemodynamic Alterations
Causes
Electrocardiogram (Fig. 24.7)
Aortic Regurgitation (AR)
Hemodynamic Alterations
Causes
Electrocardiogram (Figs 24.8 and 24.9)
Tricuspid Stenosis
Hemodynamic Alterations
Electrocardiogram (Fig. 24.10)
1. Biatrial Enlargement
2. Moderate Right Ventricular Hypertrophy
Tricuspid Regurgitation
Causes
Electrocardiogram
Pulmonary Stenosis
Pulmonary Regurgitation
FLOPPY MITRAL VALVE (MITRAL VALVE PROLAPSE) SYNDROME
Causes
Hemodynamic Alterations
Electrocardiogram (Figs 24.11 and 24.12)
1. T Wave Abnormality
2. The ST Segment Abnormalities
3. Prolongation of QT Interval and Increased QT Dispersion (QTd)
4. Arrhythmias (Fig. 24.13)
25:
Myocarditis and Cardiomyopathies
MYOCARDITIS
Causes
Pathogenic Pathophysiology
Electrocardiogram
A. Abnormalities of QRS (Fig. 25.1)
B. ST Segment Change (Figs 25.2 and 25.3)
C. T Wave Change
D. Prolongation of QTc
E. Arrhythmias/AV Blocks
Evolution of Myocarditis
CHAGAS’ MYOCARDITIS
Electrocardiogram
REVIEW AT GLANCE
CARDIOMYOPATHIES
Clinical or Functional Types
Dilated (Congestive) Cardiomyopathy
Electrocardiogram (Figs 25.4 and 25.5)
Restrictive Cardiomyopathy
Causes
Hemodynamic Alterations
Electrocardiogram
1. Amyloid Heart Disease (Fig. 25.8)
2. Sarcoid Heart Disease
3. Hemochromatosis
4. Hypereosinophilic Syndromes (Idiopathic and Loeffler's Myocarditis)
5. Carcinoid Syndrome
Endomyocardial Fibrosis (EMF)
Electrocardiogram
Arrhythmogenic Right Ventricular Dysplasia
Clinical Significance
The ECG (Figs 25.9A and B)
26:
Pericarditis
PERICARDITIS
Etiology
Electrocardiographic Abnormalities and their Pathogenesis
1. Acute Pericardial Injury and its Effect on ECG
2. Effects of Epicardial Ischemia
3. Short-circuiting Effect
Electrocardiogram in Acute Pericarditis
Evolution of Electrocardiographic Changes during Acute Pericarditis (Table 26.2)
1. ST Segment and T Wave Changes
2. Changes in PR Segment
3. Sinus Tachycardia
Differential Diagnosis
PERICARDITIS WITH EFFUSION
Genesis of Electrocardiographic Features (Figs 26.3A and B)
CHRONIC CONSTRICTIVE PERICARDITIS
27:
Acute Pulmonary Thromboembolism (Acute Cor Pulmonale)
REVIEW AT GLANCE
28:
Chronic Obstructive Pulmonary Disease (COPD) and Chronic Cor Pulmonale
CHRONIC COR PULMONALE
Chronic Obstructive Pulmonary Disease—Emphysema and Chronic Cor Pulmonale
Electrocardiogram
A. P Wave Abnormality (Figs 28.2 and 28.3)
B. QRS Abnormality (Figs 28.4 and 28.5)
C. T Wave Abnormality
D. ST Segment Changes (Fig. 28.6)
E. Arrhythmias (Fig. 28.7)
CHRONIC COR PULMONALE WITHOUT OBSTRUCTIVE DISEASE OF THE AIRWAYS
Electrocardiogram
29:
Systemic Hypertension
SECTION 10: THE DISORDERS OF CARDIAC RHYTHM
30:
Basic Physiopathologic Considerations
ANATOMY AND PHYSIOLOGY OF CONDUCTION SYSTEM
Natural Pacemakers of Heart and their Rates
CLASSIFICATION OF CARDIAC ARRHYTHMIAS
Fundamentals for Description of an Abnormal Cardiac Rhythm
Description of Dual Rhythm
BASIC APPROACH FOR ANALYSIS OF CARDIAC RHYTHM
Graphic Representation (Ladder Diagram) for Intracardiac Conduction
ARRHYTHMOGENESIS (FIGS 30.2 TO 30.4)
Abnormal Automaticity
Triggered Activity (Fig. 30.2B)
Re-entry [Re-entrant Excitation, Circus Movement, Reciprocal Beats or Echoes, or Reciprocating Tachycardia (Figs 30.3 and 30.4)]
OTHER ELECTROPHYSIOLOGICAL ABNORMALITIES LEADING TO CARDIAC ARRHYTHMIAS
Supernormal Conduction
Single Focus of Subthreshold Activity (Wedensky Facilitation)
Concealed Conduction (Figs 30.5A and B)
Parasystole
QT Dispersion (QTd)
REVIEW AT A GLANCE
31:
Sinus Rhythm and its Manifestations
SINUS RHYTHM
Definition
Electrocardiogram (Fig. 31.1)
SINUS ARRHYTHMIA
Diagnostic Clues to Sinus Arrhythmia
TYPES
Respiratory Sinus Arrhythmia
Electrocardiogram (Fig. 31.2)
Nonrespiratory Sinus Arrhythmias
Electrocardiogram (Fig. 31.3)
Ventriculophasic Sinus Arrhythmia
SINUS BRADYCARDIA
Causes
Electrocardiogram (Fig. 31.5)
SINUS TACHYCARDIA
Mechanism
Causes
Electrocardiogram (Fig. 31.6)
SINUS NODAL RE-ENTRANT TACHYCARDIA (FIG. 31.7)
Mechanisms
Electrocardiogram (Fig. 31.8)
32:
Abnormal Atrial Rhythm (Atrial Arrhythmias or Dysarrhythmias)
ATRIAL ARRHYTHMIAS
ATRIAL ECTOPICS (EXTRASYSTOLES OR PREMATURE BEATS)
Definition
Causes
Electrocardiogram (Figs 32.1 and 32.2)
Clinical Significance
ATRIAL BIGEMINY/TRIGEMINY (FIGS 32.3A and B)
ATRIAL INTERPOLATED BEAT (FIG. 32.4)
ATRIAL ESCAPE BEAT
ECTOPIC LOW ATRIAL RHYTHM (FIGS 32.1B and 32.5)
ATRIAL PARASYSTOLE
Summary
WANDERING ATRIAL PACEMAKER RHYTHM
Causes
Electrocardiogram (Figs 32.5 and 32.6)
ATRIAL TACHYCARDIAS
Causes
1. Digitalis Induced Nonparoxysmal Atrial Tachycardia (Fig. 32.7)
2. Automatic Ectopic Atrial Tachycardia (Paroxysmal Atrial Tachycardia)
Electrocardiogram (Figs 32.8A and B)
REVIEW AT GLANCE
ATRIAL RE-ENTRANT TACHYCARDIA (FIG. 32.8B)
MULTIFOCAL ATRIAL TACHYCARDIA (MAT)
Causes
Electrocardiogram (Fig. 32.9)
Clinical Significance
CHAOTIC ATRIAL RHYTHM
ATRIAL FLUTTER
Mechanism
Causes
Electrocardiogram (Figs 32.10 to 32.13)
Types
Differential Diagnosis
Clinical Significance
REVIEW AT A GLANCE
ATRIAL FIBRILLATION (AF)
Mechanisms
Causes
Electrocardiogram (Figs 32.13 and 32.14)
Slow Atrial Fibrillation (Fig. 32.16)
Aberration in Atrial Fibrillation—Ashman's Phenomenon (Fig. 32.17)
REVIEW AT GLANCE
Atrial Fibrillation at a Glance
33:
Atrioventricular (AV) Nodal Disturbances
AV NODAL (JUNCTIONAL) ESCAPE BEATS (READ CHAPTER 40—ESCAPE RHYTHM)
Electrocardiogram (Fig. 33.3)
PREMATURE AV NODAL (JUNCTIONAL) COMPLEXES/AV NODAL EXTRASYSTOLES OR ECTOPICS
Electrocardiogram (Fig. 33.4)
AV NODAL (JUNCTIONAL) RHYTHM
Causes
Electrocardiogram (Figs 33.6 and 33.7)
ACCELERATION OF AV NODAL RHYTHM (ACCELERATED AV NODAL RHYTHM OR IDIONODAL TACHYCARDIA)
Causes
Mechanism
Electrocardiogram in Accelerated Nodal Rhythm/Idionodal Tachycardia (Figs 33.8 and 33.9)
Differential Diagnosis
34:
Paroxysmal Supraventricular Tachycardias
DEFINITION
MECHANISMS
ATRIOVENTRICULAR (AV) NODAL TACHYCARDIAS
1. AV Nodal Re-entrant Tachycardia (AVNRT)
Pathogenesis—Dual Concept Mechanism Proposed for Re-entry
Mode of Conduction Through These Pathways
The Electrocardiogram in AV Nodal Re-entrant Tachycardia (Figs 34.3A to C)
2. Atrioventricular Re-entrant Tachycardia (AVRT)
Electrocardiogram (Fig. 34.6)
Differential Diagnosis of Supraventricular Tachycardia
Narrow QRS Complex Tachycardia
35:
Ventricular Arrhythmias/Dysarrhythmias
VENTRICULAR ECTOPICS OR EXTRASYSTOLES
Causes
Electrocardiogram
Variants of Ventricular Premature Complexes (VPCs)
Morphology of Ventricular Premature Complexes
Origin of Ventricular Premature Complexes
Conduction of Ventricular Premature Complexes (VPCs)
Significance of Ventricular Ectopics
Premature Ventricular Complexes Originating from the Site of Myocardial Infarction
IDIOVENTRICULAR RHYTHMS
Electrocardiographic Manifestations
Idioventricular Escape Rhythm
Causes
Electrocardiogram
Accelerated Idioventricular Rhythm
Mechanism
Causes
Electrocardiogram (Figs 35.23 and 35.24)
Clinical Significance
VENTRICULAR TACHYCARDIA (VT)
Predisposing Conditions
Electrocardiogram (Figs 35.26 to 35.30)
Differential Diagnosis of Wide QRS Complex Tachycardias
Terms Used in Reference to Ventricular Tachycardia
TORSADES DE POINTES
Causes
Mechanisms
Electrocardiogram (Fig. 35.35)
Clinical Significance
VENTRICULAR FLUTTER
Causes
Electrocardiographic Characteristics (Fig. 35.36)
VENTRICULAR FIBRILLATION (VF)
Causes or Predisposing Conditions
Mechanisms
Electrocardiogram (Figs 35.37A to C)
Classification of Ventricular Fibrillation
VENTRICULAR ASYSTOLE
Causes
Electrocardiographic Characteristics (Figs 35.38 and 35.39)
DYING HEART (AGONAL RHYTHM) PATTERN
OTHER DIAGNOSTIC ELECTROCARDIOGRAPHIC TECHNIQUES FOR ARRHYTHMIAS
Esophageal Electrocardiography
Uses
Cardiac Mapping
Signal Averaged Electrocardiogram (Figs 35.41A and B)
Candidates for Signal Averaged ECG
Criteria Used for Analysis of Late Ventricular Potentials
Types of Analysis
Procedure
36:
Reciprocal Rhythm and Reciprocal Tachycardia
RECIPROCAL RHYTHM
Mechanisms
Accessory Pathways or Bypass Tracts
Transient and Functional Unidirectional Antegrade Block in Reciprocating Circuit
A Relatively Prolonged Re-entry Period (Reciprocal Time)
Electrocardiographic Manifestations
A. Reciprocating Rhythm of Atrial Origin (Figs 36.2A to C)
Electrocardiogram (Figs 36.3 and 36.4)
B. The Reciprocal Rhythm of AV Nodal Origin
Electrocardiogram (Fig. 36.6)
C. Reciprocating Rhythm of Ventricular Origin (Fig. 36.7)
Electrocardiogram (Fig. 36.8)
WPW SYNDROME AND RECIPROCATING RHYTHM/TACHYCARDIA
WPW Syndrome and Reciprocating Tachycardia (Kent Bundle Conduction, Figs 36.9A to C)
Electrocardiographic Characteristics of Reciprocating Tachycardia (Figs 36.11A and B)
WPW Syndrome with Bundle Branch Block
Other Forms of Tachycardia in WPW Syndrome (Fig. 36.12)
TACHYCARDIA THROUGH ATRIO-HISIAN PATHWAY (LOWN-GANONG-LEVINE SYNDROME WITH TACHYCARDIA)
TACHYCARDIAS THROUGH MAHAIM FIBERS
37:
Atrioventricular Dissociation
DEFINITION
ETIOLOGY
MECHANISMS
A Disturbance of Impulse Formation
Electrocardiographic Characteristics (Figs 37.4 to 37.8)
A Disturbance of Impulse Conduction
38:
Parasystole
PARASYSTOLIC VENTRICULAR TACHYCARDIA
Electrocardiogram (Fig. 38.3)
ATRIAL PARASYSTOLE AND PARASYSTOLIC ATRIAL TACHYCARDIA
Electrocardiogram (Fig. 38.4)
NODAL PARASYSTOLE
Electrocardiogram (Fig. 38.5)
Clinical Significance
39:
Ventricular Aberrancy or Aberrant Intraventricular Conduction
PHASIC ABERRANT INTRAVENTRICULAR CONDUCTION
Mechanisms of Ventricular Aberrancy
1. Unequal Refractoriness of Bundle Branches and Critically Timed Impulses
2. Heart Rate (Long and Short Cycle Lengths)
3. Ashman Phenomenon
Conditions Associated with Ventricular Aberration
ECG Characteristic of an Aberrantly Conducted Beat or Beats (Figs 39.9 and 39.10)
VENTRICULAR ABERRANCY
Differentiation Between a Supraventricular Tachycardia with Aberration and a Ventricular Tachycardia (Table 39.2)
ATRIAL FIBRILLATION WITH VENTRICULAR ABERRATION
Analysis of Electrocardiogram (Figs 39.16 and 39.17)
ATRIAL FLUTTER WITH VENTRICULAR ABERRATION
Pathogenesis of Ventricular Aberrancy
Electrocardiogram (Figs 39.19 and 39.20)
Clinical Significance
VENTRICULAR ABERRANCY VERSUS INTERMITTENT BUNDLE BRANCH BLOCK
40:
Escape Rhythm
ESCAPE BEATS AND ESCAPE RHYTHM
Pathogenic Mechanisms
Causes
Graphic Representation of an Escape Beat/Beats
Artificial Escape Beats or Rhythm
Electrocardiographic Manifestations
Clinical Significance
41:
Ventricular Fusion Beats
VENTRICULAR FUSION COMPLEXES OR BEATS
Variations in Configuration of Ventricular Fusion Beats
Pathogenesis of Ventricular Fusion
Clinical Significance
42:
Ventricular Capture Beats
SECTION 11: ARTIFICIAL PACEMAKERS
43:
Artificial Pacemakers
ELECTROCARDIOGRAPHIC PATTERNS OF PACED COMPLEXES
Myocardial Infarction in Presence of Right Ventricular Pacing
MALFUNCTIONING OF PACEMAKERS
Abnormalities in Sensing
Remedial Measures
Remedial Measures
Remedial Measures
Causes
Abnormalities of Firing (Fig. 43.20)
Remedial Measures
Abnormalities of Capturing
Remedial Measures
Abnormal Pacing Rate
Electrocardiogram
Remedial Measures
PACEMAKER RE-ENTRANT TACHYCARDIA (ENDLESS LOOP TACHYCARDIA)
PACEMAKER SYNDROME
Twiddler's Syndrome
SECTION 12: MISCELLANEOUS DISORDERS
44:
Heart in Endocrine Disorders and Injuries
HYPERTHYROIDISM (THYROTOXICOSIS)
Electrocardiogram (Figs 44.1 and 44.2)
HYPOTHYROIDISM (MYXOEDEMA)
Electrocardiogram (Fig. 44.3)
ACROMEGALY
Electrocardiogram
CUSHING'S SYNDROME
Hyperaldosteronism
Electrocardiogram
ADRENAL INSUFFICIENCY
Electrocardiogram
PHEOCHROMOCYTOMA (CATECHOLAMINES EXCESS)
Electrocardiogram
PARATHYROID DISORDERS
HYPOTHERMIA
Electrocardiogram (Figs 44.4A to C)
ELECTRICAL INJURIES
Electrocardiogram
DROWNING
Electrocardiogram
TRAUMA TO THE HEART
Electrocardiogram (Fig. 44.6)
TUMORS OF THE HEART
Electrocardiogram (Fig. 44.7)
45:
Drugs, Poisons and the Heart
DRUGS AND THE HEART
Digitalis
Actions
Electrocardiographic Manifestations Digitalis Effect (Figs 45.1 and 45.2)
Digitalis Toxicity
Electrocardiogram (Figs 45.3 to 45.5)
Clinical Significance
Antiarrhythmic Drugs
PHENOTHIAZINES AND OTHER ANTIPSYCHOTIC DRUGS
Electrocardiogram (Fig. 45.8)
ANTIDEPRESSANTS
Antimalarial Drug
Quinine Toxicity
Antiparkinsonian Drug
Tissue Amoebicide
HEART IN SYSTEMIC POISONINGS
Organophosphorus
Electrocardiogram
Metal (Aluminum, Zinc) Phosphide Poisoning
Electrocardiographic Manifestations (Figs 45.12 to 45.19)
Clinical Significance
HEART IN ENVENOMATION
Scorpion Envenomation (Scorpion Sting Bite)
Electrocardiographic Manifestations (Figs 45.20 and 45.21)
46:
The Electrolytes and the Heart
ELECTROLYTE DISTURBANCES
HYPOKALEMIA
Causes
Electrocardiographic Manifestations (Figs 46.1A to D)
Electrocardiogram (Figs 46.2 to 46.4)
HYPERKALEMIA
Electrocardiographic Manifestations—Pathogenesis and Correlation with Potassium Levels (Fig. 46.6A to E)
Electrocardiogram (Figs 46.7 and 46.8A and B)
HYPERCALCEMIA
Electrocardiogram (Fig. 46.9)
HYPOCALCEMIA
Electrocardiogram (Fig. 46.10)
HYPOMAGNESEMIA
HYPERMAGNESEMIA
UREMIA
47:
Heart in Cerebrovascular and Neuromuscular Disorders
CEREBROVASCULAR ACCIDENT (CVA)
Electrocardiogram (Figs 47.1 to 47.4)
HYPOKALEMIC AND HYPERKALEMIC PERIODIC PARALYSIS
Electrocardiogram (Fig. 47.5)
NEUROMUSCULAR DISORDERS
Duchenne's Muscular Dystrophy
Electrocardiogram (Fig. 47.6)
Becker's Muscular Dystrophy
Electrocardiogram
Limb-Girdle Dystrophy
Myotonic Muscular Dystrophy
Electrocardiogram
Friedreich's Ataxia
Electrocardiogram (Fig. 47.7)
Guillain-Barré Syndrome
Electrocardiogram
Kugelberg-Welander Syndrome
Electrocardiogram
APPENDICES:
APPENDIX A:
Normal 12-Lead Surface ECG and Its Variations in Adults
APPENDIX B:
Analysis of an Arrhythmia
APPENDIX C:
Proforma for ECG Reporting
FURTHER SUGGESTION/ADVICE WHENEVER NECESSARY
INDEX
TOC
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