Easy ECG: Interpretation - Differential diagnosis: Part 1
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H. Ebert I Thieme III Easy ECG Interpretation Differential Diagnoses Hans-Holger Ebert, M. D. Private Practice Riesa Germany Translated by Janine Manuel, M. D. 237 illustrations Thieme Stuttgart · New York IV Library of Congress Cataloging-in-Publication Data Ebert, Hans-Holger. [EKG-Lotse English] Easy ECG: interpretation, differential diagnoses / Hans-Holger Ebert; translated by Janine Manuel. p.; cm Includes index. ISBN 3-13-135641-3 (GTV: alk. paper) – ISBN 1-58890-286-2 (TNY: alk. paper) 1. Electrocardiography. [DNLM: 1. Electrocardiography–Handbooks. 2. Arrhythmia–diagnosis–Handbooks. 3. Diagnosis, Differential–Handbooks. WG 39 E16e 2004a] I. Title. RC683.5.E5E23613 2004 616.1'207547–dc22 2004015293 This book is an authorized translation of the German edition published and copyrighted 2001 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Der EKG-Lotse. Translator: Janine Manuel, M. D., Dortmund, Germany © 2005 Georg Thieme Verlag, Rüdigerstrasse 14, 70469 Stuttgart, Germany http://www.thieme.de Thieme New York, 333 Seventh Avenue, New York, NY 10001 USA http://www.thieme.com Cover design: Martina Berge, Erbach Typesetting and graphics by Ziegler + Müller, Kirchentellinsfurt Printed in Germany by Druckhaus Götz, Ludwigsburg ISBN 3-13-135641-3 (GTV) ISBN 1-58890-286-2 (TNY) 1 2 3 4 5 Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers' leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher's consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage. V For Elena, Daniela, and my parents VI Acknowledgements My deepest thanks to Dr. Thomas Reimann for his extensive efforts in preparing the way and support in the production of this book. My greatest thanks go to Prof. Volkmann (Senior Consultant at the Erzgebirgsklinikum Annaberg-Buchholz) and to Dr. S. G. Spitzer (Head of the Department of Electrophysiology and Pacemaker Therapy, Group Practice Dresden) for the many years of fruitful cooperation and for all the knowledge they have imparted. Furthermore, I would like to thank all my colleagues in and around Dresden and Riesa, working in hospitals and private practices, who with their numerous and important suggestions have contributed to the success of this book. Riesa, Summer 2004 Hans-Holger Ebert VII Foreword Why do we need another ECG book when so many good, and some not so good, ECG textbooks, atlases, manuals, and guides are available? My former colleague of many years, Dr. Hans-Holger Ebert, has written an ECG guide which bridges the gap between the ECG atlases and textbooks based on electrophysiology. It gives the reader a closer understanding of the subject, including valuable ECG conduction diagrams, which can be used for teaching purposes, and clear, standardized schematic diagrams. Corresponding characteristic ECGs and the basics of electrophysiology are explained in a manner which makes them easily comprehensible. Konrad Spang, one of the pioneers of cardiology in Germany, said in 1957: "The correct interpretation of rhythm disorders often demands great effort and detailed in-depth analysis. Conducting such analyses is of huge didactic value. This is a pathway for the development of the ability to make exact observations and also sharpens the senses in other areas …" Easy ECG meets these demands. The author has linked electrocardiographic phenomena and the underlying electrophysiological principles with practical conclusions for clinical diagnosis and treatment. Many years of experience in cardiology in hospital and outpatient settings have been of value to the author, and the numerous internships he has supervised and lectures he has given have benefited his teaching skills. I hope Easy ECG will draw many interested readers and contribute to an in-depth understanding of current diagnostic and therapeutic options to be derived from ECG analysis, just as a pilot boat guides ships safely in and out the harbor. Hans Volkmann Professor and Senior Consultant Internal Medicine Erzgebirgsklinikum Annaberg IX Contents 1 The Human Heart . . . . . . . . . . . . . . . . . . 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Basic Anatomy . . . . . . . . . . . . . . . . . . . . . . Anatomy of the Conduction System . . The Sinus Node . . . . . . . . . . . . . . . . . . . . . The Compact AV Node . . . . . . . . . . . . . . . The Bundle of His . . . . . . . . . . . . . . . . . . . The Bundle Branches . . . . . . . . . . . . . . . . The Slow Pathway Region . . . . . . . . . . . The Fast Pathway Region . . . . . . . . . . . . The Isthmus Region . . . . . . . . . . . . . . . . . 2 2 3 3 4 4 5 5 6 2 The Conduction Diagrams and Text Fields . . . . . . . . . . . . . . . . . . . . . 7 2.1 2.2 2.3 2.4 2.5 2.6 Basic Concepts . . . . . . . . . . . . . . . . . . . . . . Impulse Formation in the Sinus Node Depolarization of the Atria (P Wave) . Conduction of the AV Node . . . . . . . . . . Depolarization of the Ventricles . . . . . . Further Explanations . . . . . . . . . . . . . . . . 8 8 9 9 10 10 3 Cardiac Rhythm Disorders and Conduction Disorders . . . . . . . . . 13 Sinus Arrythmias . . . . . . . . . . . . . . . . . . . . AV Conduction Disorders . . . . . . . . . . . . Right Bundle Branch Block . . . . . . . . . . . Left Bundle Branch Block . . . . . . . . . . . . Mixed Types of Block . . . . . . . . . . . . . . . . Supraventricular Extrasystole . . . . . . . . Atrial Tachycardia . . . . . . . . . . . . . . . . . . . "Atypical" Atrial Flutter . . . . . . . . . . . . . . "Typical" Atrial Flutter . . . . . . . . . . . . . . . Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . Reentry Tachycardia . . . . . . . . . . . . . . . . . Ventricular Extrasystole . . . . . . . . . . . . . Ventricular Tachycardia . . . . . . . . . . . . . Ventricular Flutter . . . . . . . . . . . . . . . . . . Ventricular Fibrillation . . . . . . . . . . . . . . 14 30 47 55 63 66 68 70 71 74 79 88 91 95 96 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12 3.13 3.14 3.15 4 Coronary Heart Disease and Myocardial Infarction . . . . . . . . 4.1 Coronary Anatomy . . . . . . . . . . . . . . . . . . 4.2 Stress-Induced Ischemia in Coronary Heart Disease . . . . . . . . . . . . . . . . . . . . . . . 4.3 Acute Coronary Syndrome . . . . . . . . . . 4.4 Acute Myocardial Infarction . . . . . . . . . 4.5 Resting Ischemia in the Anterior Wall Region Following Posterior Wall Infarction . . . . . . . . . . . . . . . . . . . . . . . . . . 4.6 Stress-Induced Ischemia in the Infarct Region Following Posterior Myocardial Infarction . . . . . . . . . . . . . . . . . . . . . . . . . . 5 97 98 99 101 102 109 110 Other ECG Changes . . . . . . . . . . . . . . . . 113 5.1 Left Ventricular Hypertrophy . . . . . . . . 5.2 Hypertrophic Obstructive Cardiomyopathy . . . . . . . . . . . . . . . . . . . . 5.3 Mitral Valve Prolapse Syndrome . . . . . 5.4 Pericarditis and Myocarditis . . . . . . . . . 5.5 Right Ventricular Hypertrophy . . . . . . 5.6 Acute Pulmonary Embolism . . . . . . . . . 5.7 Dextrocardia . . . . . . . . . . . . . . . . . . . . . . . 5.8 Arrhythmogenic Right Ventricular Dysplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.9 Brugada Syndrome . . . . . . . . . . . . . . . . . 5.10 QT Syndrome . . . . . . . . . . . . . . . . . . . . . . . 5.11 Medication-Related ECG Changes . . . . 5.12 ECG Changes With Electrolyte Shifts . 5.13 P Wave Changes . . . . . . . . . . . . . . . . . . . . 114 116 117 117 119 120 121 122 122 123 124 130 132 Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 1 1 The Human Heart 2 1 The Human Heart 1.1 Basic Anatomy Superior vena cava Aorta Interatrial septum Fossa ovalis Left atrium Right atrium Mitral valve Crista terminalis Opening of coronary sinus Left ventricle Opening of inferior cava Tricuspid valve Interventricular septum Inferior vena cava 1.2 Anatomy of the Conduction System Sinus node AV node Bundle of His Bundle branches Slow pathway region Fast pathway region Isthmus region 1 The Human Heart 3 1.3 The Sinus Node Sinus node Size/form: 10–20 mm, spindle-shaped Location: In the first third of the sulcus terminalis along the axis between the opening of the superior vena cava and the right subepicardial auricle Blood supply: Sinus node artery (arises from RCA in 50–59%, from RCX in 20–38%, dual blood supply in 3–30%) Innervation: Parasympathetic postganglionic and sympathetic fibers Function: Physiological site of impulse formation Electrophysiological significance: Site of sinus node reentry 1.4 The Compact AV Node Size/form: Compact AV node ca. 1 × 3 × 5 mm Location: Base of the right atrium at the point of the so-called Koch triangle (between the tricuspid annulus and the eustachian valve), subendocardial Blood supply: AV node artery (arises from RCA in 90%, in 10% from RCX) Innervation: Parasympathetic postganglionic and sympathetic fibers Function: Impulse conduction from the atrium to the bundle of His Electrophysiological significance: Secondary site for impulse formation, area of slowest impulse conduction (0.2 m/s) This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
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