Learn ECG in a Day: A Systematic Approach Prem Alva, Sajjan Madappady, EVS Maben
INDEX
Page numbers followed by f refer to figure, fc refer to flowchart, and t refer to table.
A
Adrenaline 67
Anemia 59
Aneurism, ventricular 66, 83
Angina pectoris 84
Anxiety 59
Aorta, coarctation of 40
Aortic stenosis 24, 40, 77
Apex beat
left ventricular type of 79
normal 78
right ventricular type of 74, 76, 79
Arrhythmias 5, 49, 62, 71fc
interpretation of 71
systematic interpretation of 71
Artery
left circumflex 33, 38f
pulmonary 77
Asthma, bronchial 24
Atria 50, 74, 79, 80
disturbance of 49
Atrial cells 4
Atrial contraction, type of 65
Atrial depolarization 4f
Atrial escape beat 55, 56f
Atrial fibrillation 20, 49, 59, 62, 62f, 65, 70, 81
Atrial flutter 49, 59, 64, 64f, 65, 81
Atrial premature
beat 54t
contraction 49
Atrial septal defect 24, 74
secundum 74
Atrial size 7478
Atrioventricular block
first degree 25f
third degree 26, 26f, 50
Atrioventricular canal defect, partial 74
Atrioventricular nodal re-entry tachycardia 61, 61f, 62, 62f
Atrioventricular node 3, 4, 56
canal defect, common complete 76
disturbance of 49
Axis 20, 72
B
Baseline vibration 63
Bilirubin, deposition of 59
Blood pressure
high 63
measurement 79
Bradyarrhythmias 71
Bradycardia 84, 85
Bundle branch block 4, 42, 50
Bundle of His 3, 4, 56, 62
C
Capture beat 65
Cardiac apex, right ventricular type of 74
Cardiomyopathy, hypertrophic 21, 40, 85
Carotid sinus massage 62
Cells, myocardial 4
Cerebrovascular accident 85
Chamber enlargement 73, 80
Chest
leads 9f, 17, 17f, 83
placement of 12, 12f
wall
thick 83
thin 83
Conduction system 59
Congenital anomaly detection 72
COPD 82
Cor pulmonale 21, 41, 45
Coronary artery 33
anomalous left 77
Crochetage pattern 74
Culprit coronary vessel, detection of 38
Cyanosis 78
absence of 80
central 78
deep 78
presence of 80
Cyanotic spells 78
D
Deafness, congenital 85
Delta waves 69f
Dextrocardia 81, 82
Digitalis 67
Digoxin
effect 84
toxicity 84
Dilated right atrium 76, 78
Down's syndrome 76
Drowning 67
Drug over dosage 67
Dual atrioventricular nodal pathway, concept of 60
Dyspnea, exertional 74
E
ECG
basics of 6
features 75, 76, 78
findings 65
history of 1
interpretation, pediatric 72
leads 8
paper 13f
patterns, labeled normal 17f
standardization 82
strip, parts of 15f, 15t
systematic interpretation of 18
wave morphology 14f
Ectopic beats 50
high nodal 81, 82
Ejection click 76, 77, 79
Ejection systolic murmur 74, 7679
Electrical activity, normal spread of 4
Electrical cavity, spread of 4f
Electrocardiogram, systematic interpretation guidelines for 18
Electrocardiography 6
complete 1f
Electrode 7, 32
Emphysema 21, 24, 82, 83
Endocardial surface 4f
Epigastric pulsation 41
Exercise 59
Extreme left axis deviation 76
Extremities, bluish discoloration of 7779
F
F wave, fibrillating 63
Fallot's tetralogy 21, 41
Fatigue, exertional 7678
Fever 59
Fibrillation 65t
Flutter 65t
Fusion beat 66
G
Great vessels, transposition of 78
H
Heart 4, 34f
block 5
complete 26
first degree 72, 82
mobitz type 26, 26f, 50, 82
second degree 26, 49, 72
third degree 72, 81
conduction system of 3, 3f
disease
acyanotic congenital 74
congenital 72, 73
cyanotic congenital 77
obstructive acyanotic 76
rheumatic 63, 64
failure 26, 78
early infancy symptoms of 77
symptoms of 76, 79
marked clockwise rotation of 82
rate 54, 62, 80
normal 73t
sound
absent 67
fixed split second 74
loud second 75
normal 75
single second 78
wide split second 74, 76, 79
Hurried breathing 75, 79
since neonatal period 78
Hypercalcemia 84
Hyperkalemia 81, 83, 84
Hypertension 63, 64
pulmonary 41
significant pulmonary 75
systemic 40
Hyperthermia 84
Hyperthyroidism 84
Hypertrophy 39, 72
left atrial 81
right atrial 81
right ventricular 21, 41, 45, 7276, 78, 79, 82
ventricular 7479, 83, 84
Hypocalcemia 85
Hypokalemia 66, 67, 84
Hypomagnesemia 66, 67
Hypothermia 59, 82, 83, 85
Hypothyroidism 59, 82, 83, 84
I
Impulse
conduction 44f, 46f
disorders of 49
formation, disorders of 49
Incomplete compensatory pause 50, 51, 51f
Infarction 29, 29f, 30
Injury 28, 28f
Intra-atrial conduction 24, 24f, 25f
Ischemia 27, 28f
myocardial 84
non-infarction transmural 83
Isoprenaline 67
J
Jaundice, obstructive 59
Jervell and Lange-Nielsen syndrome 85
Junctional escape beat 55, 57f
K
Kent bundle 69f
L
Leads 8f, 9fc, 11f
placement of 11
Left anterior descending artery 33
infarction 35f37f
Left anterior hemiblock 21, 47, 47f, 50
Left atrial
abnormality 24t
enlargement 22, 25f
Left axis deviation 21, 21f, 47, 74, 80
Left bundle branch 3
block 21, 45, 46f, 48, 50, 82, 83
ECG of 45f
Left posterior hemiblock 21, 47, 47f, 50
Left ventricle quadrant 34f
Left ventricular
apex 75
function 66
hypertrophy 21, 39, 72, 75, 77, 78, 82
ECG of 39f
mild 75
strain pattern 40, 40f
third heart sound 77
Limb leads 9f
placement of 12, 12f
Lips, bluish discoloration of 77, 78
Long QT interval 85
Lower respiratory infections, recurrent 74, 75, 79
Lown–Ganong–Levin syndrome 82
M
Massive pleural effusion, left sided 82
Mitral regurgitation 24
Mitral stenosis 24, 63, 64
Multiple re-entrant wavelets 63f
Murmur, pansystolic 75, 77
Myocardial infarction 82, 84
acute 27, 27fc, 32f, 45, 48, 63, 64, 66, 67, 8385
anterior 59
inferior wall 59
true posterior 84
anterior 82
anterolateral wall 31
anteroseptal 82
inferior wall 31, 31f
subendocardial 84
true posterior 82
Myocarditis 66, 85
Myocardium, ventricular 4f
N
Nodal blocks 49
Nodal premature beat 54t
Non-ST elevation myocardial infarction 33, 33f
Noonan syndrome 76
Normal ECG 13
morphology 13
pattern 15, 16f
O
Obesity 82, 83
P
P mitrale 22, 23f
P pulmonale 23, 23f
P wave 65, 68, 81
absent 63, 81
atrial depolarization 14
different morphology of 22f
inverted 24, 54, 81
morphology 21, 22f, 72
variable 81
multiple 81
small 81
tall 81
wide 81
Pacemakers
order of 50fc
rates of 4
wandering 81
Paroxysmal supraventricular tachycardia 49, 60
Pericardial effusion 82, 83, 84
Pericarditis
acute 83, 84
chronic 83
Pneumothorax, left sided 82
Posterior descending artery 33
involvement 37f
P-R interval 25, 72
prolonged 82
short 82
variable 82
Premature beat 50, 50f, 57t
atrial origin of 54f
nodal origin of 54f
Prinzmetal's angina 83
Pulmonary embolism 24, 45, 82
Pulmonic valve stenosis 24
Pulse
absent 67
bounding 79
collapsing 79
pressure
narrow 77
wide 79
volume, normal 79
Purkinje cells 4
Purkinje fibers 3, 56
Q
Q wave 82
QRS
axis 7478
complex 14, 65, 67, 83
wide 42
high voltage 83
low voltage 83
variable 83
wave
different patterns of 15f, 16f
morphology 27
wide 83
Q-T interval 84
short 84
Quadrant infarction
anteroseptal 35
anterosuperior 36
posterolateral 37, 38
R
R wave 82
progression, normal 17, 17f
small 82
tall 82
Rabbit ear pattern 42, 42f
Raised intracranial pressure 59
Rate 19, 65, 67, 68
Re-entry circuit 69
Respiration 67
Respiratory infections, recurrent 75, 78
Retrograde conduction 81
Rheumatic fever, history of 63
Rhythm 20, 52, 65, 67, 68, 72, 7479
abnormalities of 57
atrial 59
high nodal 55, 55f, 81
idioventricular 67, 68f, 81, 83
irregular 20
junctional 49, 54
low nodal 55, 55f
mid nodal 55, 55f, 81
nodal 54, 81, 82
sinus 60
ventricular 65
Right atrial
abnormality 24, 24t
enlargement 23, 24f, 74, 7981
Right axis deviation 21, 21f, 42, 47, 74, 76, 78, 79
Right bundle branch block 21, 42, 44f, 50, 82, 83
ECG of 43f
Right left axis, deviation of 21
Right ventricular
apex 76
hypertrophy 21, 41, 45, 7276, 78, 79, 82
ECG of 41f
strain pattern 41, 42f
Romano–Ward syndrome 85
R-R interval 19f, 20f
irregular 20f
S
Septal depolarization 4f
Shock 59
Sick sinus syndrome 59
Sinoatrial blocks 49
Sinoatrial nodal parts 54f
Sinoatrial node 3, 4, 56
block 55
Sinus 62t
arrest 55, 56f
arrhythmia 20, 49, 57
ECG of 58f
bradycardia 49, 57, 58
ECG of 58f
mechanism, disturbances of 49
pause 55, 56f
rhythm 60
conduction in 60f
normal 7479
tachycardia 49, 57, 59
ECG of 59f
Soft ejection systolic murmur 75, 78
Sokolow–Lyon criteria 39, 41
ST depression 84
ST elevation 31, 3537, 38fc, 77, 83
ST segment 14, 28f, 83
Stenosis
congenital pulmonary 76
pulmonary 41, 76
severity of 76
Stokes–Adams attacks 26
Strain pattern 40
Sudden death 70, 85
Supraventricular premature beat 51, 53
ECG of 52f
Supraventricular tachycardia 62t
Syncope 70, 77, 85
T
T inversion 84
T wave 84
inverted asymmetric 42
small 84
tall 84
ventricular repolarization 14
Tachyarrhythmias 71
Tachycardia 75, 77, 79, 84
atrial 61, 61f, 65, 65t, 81
junctional 49
sinus 49, 57, 59
supraventricular 59, 62t, 69, 81
ventricular 49, 65, 66f, 68t, 81, 83
Tachypnea 76
Tetralogy of Fallot 24, 77, 78
Thyrotoxicosis 59, 63, 64
Torsades de pointes 66, 67f, 83
Total anomalous pulmonary venous connection 78
Tricuspid atresia 79
Truncus arteriosus 79
U
U wave 84
prominent 84
V
Vagal stimulation 84
Vagal tone 58
Valvular lesions 63, 64
Ventricles, disturbance of 49
Ventricular bigeminy 53
Ventricular ectopic 49, 81, 83, 84
Ventricular escape beat 55, 57f
Ventricular fibrillation 20, 49, 67, 67f, 68f, 83
Ventricular myocardium 4f
anteroseptal region of 4f
Ventricular premature beat 5153
ECG of 53f
Ventricular septal defect
large 75
moderate 75
Verapamil 59
W
Wenckebach block 49
Wenckebach phenomenon 26, 82
Williams syndrome 77
Wolff–Parkinson–White syndrome 21, 68, 82, 83
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Learn ECG in a Day: A Systematic Approach
Learn ECG in a Day: A Systematic Approach
Second Edition
Sajjan Madappady MBBS MD MBA PGDDM International Medical Consultant Managing Director, Dynamic Medicare Pvt Ltd Assistant Professor, Department of Community Medicine, AJIMS and RC President, Dynamic Health and Education Foundation (NGO) Certified Medical Tourism Professional by the American Medical Tourism Association, USA Advisory Scientific Consultant for Guangdong Institute of Targeted Tumour Intervention and Prevention, CHINA www.drsajjan.com EVS Maben MBBS MD Professor and HOD, Department of General Medicine AJ Institute of Medical Sciences and Research Centre Mangalore, Karnataka, India Prem Alva MBBS MD Consultant Interventional Paediatric Cardiologist AJ Hospital and Research Centre Mangalore, Karnataka, India
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Learn ECG in a Day: A Systematic Approach / Sajjan Madappady, EVS Maben, Prem Alva
First Edition: 2013
Second Edition: 2020
9789389587265
Printed at
Dedicated to
My parents, Smt Prasadini Madappady and Sri Radhakrishna Madappady who have unconditionally been constant source of love, support and encouragement
Preface to the Second Edition
Sajjan Madappady MBBS MD MBA PGDDM
International Medical Consultant
Managing Director, Dynamic Medicare Pvt Ltd
Assistant Professor, Department of Community Medicine, AJIMS and RC
President, Dynamic Health and Education Foundation (NGO)
Certified Medical Tourism Professional by the American Medical Tourism Association, USA
Advisory Scientific Consultant for Guangdong Institute of Targeted Tumour
Intervention and Prevention, CHINA
My journey as an author of this book since the last 8 years has been very adventurous. The satisfaction I have seen in the thousands of students, in those, whom I have passed on my knowledge and understanding has inspired me to keep going and improving to add value.
I am very grateful for the student community for receiving this book very positively. I have been privileged to be invited as a guest for numerous international and national universities to create a workshop on ECG interpretation. All along this journey, I have improvised on my techniques of effective knowledge delivery.
I have been addressing the pediatric ECG for many pediatricians. In collaboration with Dr Prem Alva, in this edition, we have added a special chapter on pediatric ECG interpretation.
I always believe “Dare to be Different” and that's what adds value in life. Have a vision and take a stand for its accomplishment. Life always has a way to make things work for you when you work toward it.
Your opinion is valuable. I request you to give me the feedback and help in the improvement of this book to my E-mail: dynamicsajjan@gmail.com or www.drsajjan.com/contact.
Feel free to contact me anytime if you have difficulty in understanding the concepts. Happy reading!
Preface to the First Edition
Present-day cardiology is undergoing immense advancements. ECG still remains the key stone in the clinical management of various cardiovascular and metabolic disorders.
Currently, interpreting ECG for medicos is a difficult task. So my efforts into this book endeavor to equip them to interpret ECG confidently and independently.
My experience with trying to understand ECG as an undergraduate made me realize that all the current books on ECG are merely a source of information. So unlike other books, the purpose of this book is to help medicos to develop a systematic approach to ECG and come to a diagnosis in a clinical set-up. However, reading the book alone will not suffice until interpreting is not put into practice.
Your opinion is valuable. I request you to give me a feedback and help in improvement of this book to my E-mail: dynamicsajjan@gmail.com.
In the end,
Observe, record, tabulate, and communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell and know that by practice alone you can become expert.”
—William Osler
WISHING YOU ALL THE BEST!
Sajjan Madappady
Acknowledgments
When emotions are poured, words, sometimes, are not sufficient to express our thanks and gratitude.
My sincere gratitude to Dr EVS Maben, Professor and Head, Department of Medicine, AJ Institute of Medical Sciences, who is my teacher, guide and inspiration behind this book.
I extend my sincere gratitude to Shri AJ Shetty, President, Laxmi Memorial Education Trust, and Shri Prashanth Shetty, Vice-President, Laxmi Memorial Education Trust, for their support. I extend my sincere gratitude to Dr Ramesh Pai, Dean, AJIMS, Mangalore and Dr E Keshava Bhat, Professor of Medicine (Retd), Mangalore, for reviewing this book.
I extend my heartfelt gratitude to Dr Purushotham, Interventional Cardiologist, AJHRC, Mangalore, for taking his valuable time in evaluating this book and giving his expert opinion. I extend my sincere gratitude to Dr Krishna Kumar PN, MCH (CVTS), Apollo Hospitals, Chennai; Dr Naveen NS (GS), District Hospital, Madikeri, Kodagu; Dr BK Rajeshwari, MS (O & G), Bangalore Medical College, Bengaluru; Dr Praveen NS, Senior Clinical Fellow in Fetal Medicine, Royal London Hospital, London, UK; Dr Ashwini A, Clinical Fellow in Anesthesiology, Luton and Dunstable NHS Trust, UK, for taking their precious time in reviewing this book and giving their valuable views.
I would like to thank my mother, Smt Prasadini M; my father, Sri Radhakrishna M; my sister, Ms Madhura M, and all my family members for their encouragement and support.
It is my immense pleasure to pay gratitude to my teacher Mrs Olivia Periera.
Words are hard to find when it comes to highlighting the role of my friends in making this book.
I express my special thanks to Dr Nandish VS, Dr Ajey M Hegde, Dr Ravichandran K, Dr Chinthan S, Dr Anup Yogi and all my friends for their constant support.
I express my gratitude to my dearest friend and colleague Dr Rex Pais Prabhu for his constant support and aptly titling my book Learn ECG in a Day: A Systematic Approach.
My gratitude to Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for accepting my book and bringing out the contents and pictures in an elegant manner.
Last but not least, I gracefully acknowledge and thank in anticipation all readers, whom I am confident will act as a guiding force in improving and upgrading the contents of this book.