Basic and Bedside Electrocardiography

464 Pages·2009·43.883 MB·English

by  Romulo F. Baltazar MD FACC

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Basic and Bedside
Electrocardiography
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Basic and Bedside
Electrocardiography
Romulo F.Baltazar,MD,FACC
Director,Noninvasive Cardiology
Sinai Hospital of Baltimore
Assistant Professor,Medicine
Johns Hopkins University
Baltimore,Maryland
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9 8 7 6 5 4 3 2 1
Library ofCongress Cataloging-in-Publication Data
Baltazar,Romulo F.
Basic and bedside electrocardiography / Romulo F.Baltazar.
p.;cm.
Includes index.
ISBN-13:978-0-7817-8804-5
ISBN-10:0-7817-8804-8
1. Electrocardiography. I.Title.
[DNLM: 1. Electrocardiography. 2. Heart Diseases—diagnosis. 3. Heart
Diseases—therapy. WG 140 B197b 2009]
RC683.5.E5B283 2009
616.1(cid:2)207547—dc22
2008056135
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This book is dedicated to my wife, Ophelia,
for her inspiration, support and encouragement in
the preparation of this book.
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Preface
More than 100 years since its introduction,electrocar- Hartman, Kevin Hayes, Khawaja Farook, Jason Javillo,
diography continues to provide invaluable clinical Jennifer Morales, Ubadullah Sharief, Ledys de Marsico,
information.Even with the development of modern and Celian Valero,Samarina Ahmad,Kweku Hayford,Haritha
more expensive technologies,its significance has not de- Pendli,Maya Morrison,and many others.I am also grate-
clined.To the contrary,its clinical application continues ful to Kittane Vishnupriya for his very helpful comments
to expand,and presently,it is the most utilized diagnostic and for the ECG that he painstakingly obtained to illus-
modality in the whole practice ofmedicine.In the hospi- trate the significance ofthe posterior leads in the diagno-
tal setting,it is routinely used to monitor both cardiac and sis of posterolateral myocardial infarction when he was a
noncardiac patients, especially in acute care units and coronary care resident.I am also grateful to Drs.Gabriela
during the performance of various cardiac and noncar- Szabo,Ameena Etherington, and Soma Sengupta for re-
diac procedures. Thus, the information provided by the viewing chapters in the book,and Laura Baldwin,our su-
electrocardiogram should be standard knowledge for perb cardiology technician,who has taught me how to re-
every medical and paramedical professional who is in- trieve and record electrocardiograms from our archives.
volved with patient care. I am also grateful to Dr.Morton Mower who has been
This book is purposely written in a format that will my mentor since I was a resident.His suggestions for im-
assist the beginner, including medical students, nurses, proving the book are greatly appreciated.I would also like
and paramedical professionals, in understanding basic to express my deep appreciation to Dr.Steven Gambert,
electrocardiography. It is also intended for interns, resi- Chief of the Department of Medicine, Johns Hopkins
dents,physician assistants,fellows,anesthesiologists,and University/Sinai Hospital Program in Internal Medicine,
clinical cardiologists by including standard of care treat- for his support and encouragement and for his enthusi-
ment ofpatients with electrocardiographic abnormalities asm in having this book published.
based on the most recent practice guidelines when guide- Finally,I am grateful to my daughter,Cristina,who is
lines are available. Thus, the book is a combination of instrumental in teaching me how to use the computer in
both basic and bedside electrocardiography. the preparation ofthis book and my son Romulo,Jr who
The book integrates the comments and suggestions of decided on Radiology as his specialty, for his comments
many interns, residents, and attending physicians to and suggestions for simplifying some of the chapters,
whom I owe a great deal ofgratitude.I would like to thank especially those dealing with Basic Electrocardiography.
Drs. Miruais Hamed, Paul Aoun, Eileen Zingman, Olga
Szalasny,Katja Vassiliades,Manish Arora,Onyi Onuoha, Romulo F.Baltazar,MD,FACC
Brandon Togioka, Darshana Purohit, Ranjani Ra- Director,Noninvasive Cardiology,Department ofMedicine
manathan,Binu Matthew,Paolo Caimi,Mulugeta Fissha, Johns Hopkins University/Sinai Hospital Program in
Hany Bashandy, Cindy Huang, Suzan Fattohy, Rachel Internal Medicine
vii
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Contents
Preface vii
1 Basic Anatomy and Electrophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Basic Electrocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3 The Lead System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
4 The Electrical Axis and Cardiac Rotation . . . . . . . . . . . . . . . . . . . . . . . . . 30
5 Heart Rate and Voltage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
6 Depolarization and Repolarization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
7 Chamber Enlargement and Hypertrophy . . . . . . . . . . . . . . . . . . . . . . . . . 62
8 Atrioventricular Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
9 Intraventricular Conduction Defect:Fascicular Block . . . . . . . . . . . . . . 112
10 Intraventricular Conduction Defect:Bundle Branch Block . . . . . . . . . . 120
11 Intraventricular Conduction Defect:Trifascicular Block . . . . . . . . . . . . 138
12 Sinus Node Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
13 Premature Supraventricular Complexes . . . . . . . . . . . . . . . . . . . . . . . . . 167
14 Sinus Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
15 Supraventricular Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
16 Supraventricular Tachycardia due to Reentry . . . . . . . . . . . . . . . . . . . . . 187
17 Supraventricular Tachycardia due to Altered Automaticity . . . . . . . . . . 211
18 Atrial Flutter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
19 Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
20 Wolff-Parkinson-White Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
21 Ventricular Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
22 Wide Complex Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
23 Acute Coronary Syndrome:ST Elevation Myocardial Infarction . . . . . . 331
24 Acute Coronary Syndrome:Non-ST Elevation Myocardial
Infarction and Unstable Angina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
25 Electrolyte Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
26 The ECG of Cardiac Pacemakers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
Appendix:Commonly Used Injectable Pharmacologic Agents . . . . . . . . . . . . . 435
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
ix
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