Clinical Electrocardiography: A Textbook, Fourth Edition

553 Pages·2012·22.92 MB·English

by  Antoni Bayes De Luna(auth.)

Clinical Electrocardiography
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Companion website
This book is accompanied by a website:
www.wiley.com/go/bayes/electrocardiography
The website includes:
• Helpful Multiple Choice Questions
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Clinical
Electrocardiography
A Textbook
FOURTH EDITION
ANTO NI BAYÉS DE LUN A
Emeritus Professor of Cardiology, Autonomous University of Barcelona
Senior Investigator, Institut Català Ciències Cardiovasculars
Hospital Sant Pau
Senior Consultant, Hospital Quiron
Barcelona
Spain
With contributions from:
A. BAYÉS GENIS, R. BRUGADA, M. FIOL AND W. ZAREBA
A John Wiley & Sons, Ltd., Publication
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Contents
Preface, vii Part 4 Arrhythmias
Foreword by Dr Eugene Braunwald, ix
14 Mechanisms, Classification, and Clinical Aspects
Foreword by Dr Marcelo Elizari, x of Arrhythmias, 279
Recommended Reading, xi 15 Active Supraventricular Arrhythmias, 301
16 Active Ventricular Arrhythmias, 329
Part 1 Introductory Aspects 17 Passive Arrhythmias, 354
18 Diagnosis of Arrhythmias in Clinical Practice:
1 The Electrical Activity of the Heart, 3
A Step-by-Step Approach, 373
2 The History of Electrocardiography, 11
3 Utility and Limitations of the Surface
Part 5 The Clinical Usefulness
ECG: Present and Future, 16
of Electrocardiography
19 The Diagnostic Value of Electrocardiographic
Part 2 The Normal ECG
Abnormalities, 387
4 The Anatomical Basis of the ECG: From Macroscopic 20 The ECG in Different Clinical Settings of Ischemic
Anatomy to Ultrastructural Characteristics, 25 Heart Disease, 402
5 The Electrophysiological Basis of the ECG: From Cell 21 Inherited Heart Diseases, 453
Electrophysiology to the Human ECG, 34
22 The ECG in Other Heart Diseases, 473
6 The ECG Recording: Leads, Devices,
23 The ECG in Other Diseases and Different
and Techniques, 54
Situations, 494
7 Characteristics of the Normal Electrocardiogram:
24 Other ECG Patterns of Risk, 511
Normal ECG Waves and Intervals, 67
25 Limitations of the Conventional ECG:
8 Diagnostic Criteria: Sensitivity, Specificity
Utility of Other Techniques, 523
and  Predictive Value, 95
Index, 541
Part 3 Abnormal ECG P atterns
Color plate section facing p. 276
9 Atrial Abnormalities, 103
10 Ventricular Enlargement, 123
11 Ventricular Blocks, 158
12 Ventricular Pre-excitation, 203
Companion website
13 Ischemia and Necrosis, 216
www.wiley.com/go/bayes/electrocardiography.com
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Preface
The 12-lead surface electrocardiogram (ECG) is the best the surface ECG. We also provide an overview of other
technique to record the electrical activity of the heart and ECG techniques that we use to complement the diagnostic
although it initially had a diagnostic value only, it has capacity of the 12-lead surface ECG.
been demonstrated in recent years that it has very impor- After this preface, we provide a list of recommended
tant clinical implications that are very useful for risk reading which will help the reader to better understand
stratification as well as choosing the best management of the concepts discussed here. This list includes the classical
different heart diseases. works that have greatly influenced me personally, in
In this book we encompass all this new clinical knowl- addition to more recent books that provide new
edge of the ECG with the aim of producing a clear text knowledge in all aspects of electrocardiology. After each
that is easy to understand for clinicians and trainees. chapter there are also expanded references on the topics
The first part is a review of the electrical activity of the discussed.
heart, the history of electrocardiography, and its useful- Finally, this edition has an important innovation for
ness and limitations. me. Although I have written the book alone, I have incor-
In the second and third parts we discuss the origins porated contributions from A. Bayés-Genis, R. Brugada,
of normal ECG patterns and the changes that various M. Fiol, and W. Zareba. They have completed and
heart  diseases produce in ECG morphology. This reviewed different sections. These doctors began as my
includes the ECG patterns produced by atrial abnormali- fellows and collaborators and for the last 20 years have
ties, ventricular enlargement, ventricular blocks, pre- excelled in different fields of cardiology that are very
excitation, ischemia, and necrosis. In all these situations much related to the ECG. Their most valuable contribu-
we identify the most important clinical implications tion throughout the years has been to inspire me to
derived from these diagnoses. With regard to normal seach for new ideas in the field of electrocardiology. We
and abnormal ECG patterns, we have attempted to have built a team that has adopted a similar philosophy
reflect our conviction that ECG patterns should not be while adding new input and flavor to future editions
memorized, but rather understood in terms of how they of the book. I am very much indebted to them for having
are originated. The best way to demonstrate this is a accepted this task.
deductive approach based on electrocardiographic–vec- My gratitude also goes out to other specific collab-
torcardiographic correlations. However, when we under- orators including D. Goldwasser, J. Garcia Niebla,
stand this correlation it is no longer necessary to record I.  Cygankiewicz, A. Perez Riera, T. Martinez Rubio,
VCG loops in order to improve on the information given M. Subirana, J. Guindo, V. de Porta, X. Viñolas, and
by the ECG curves. J.  Riba, among many others. My sincerest thanks to
Part 4 deals with the ECG diagnosis of arrhythmias Professor E. Braunwald from United States who has been
based on the changes produced by various arrhythmias in the greatest pioneer and master in so many fields of
the surface ECG. A deductive approach is again the best Clinical Cardiology, and to Professor M. Elizari from
way to diagnose arrhythmias. We briefly discuss the most Argentina, who also excels for his mastership in experi-
important clinical implications of various arrhythmias. mental and clinical electrophysiology, both of whom have
For further information, the reader should consult our been masters and friends and who have very generously
book Clinical Arrhythmology (Wiley-Blackwell 2011), from written the forewords.
which we have taken some of the ECG figures. The front cover illustrates the changes in the ECG
Part 5 of the book deals with the clinical usefulness of recording of acute STEMI (see Figure 20.3) over the past
electrocardiography. Here we explain the diagnostic 40 years. Underneath is the sillohuette of the “Sagrada
value of different ECG alterations, the ECG changes in Familia” temple, “thrillering” arrhythmia (figure in itself),
different heart diseases and situations, the ECG as a which still astonishes me every day as I make my way to
marker of poor prognosis, and finally the limitations of work at my beloved Sant Pau Hospital in Barcelona.
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viii Preface
I would also like to extend my thanks to Montse Saurí delve inside the book it will engage you like a passionate
for her secretarial assistance, which she performed excel- novel. Finally, my sincerest thanks to Mr T. Hartman from
lently and as usual, with a smile on her face. Wiley-Blackwell for his confidence in this project and also
Finally I thank my family, especially my wife Maria to Cathryn Gates and Britto Fleming Joe for their excellent
Clara, who has supported me patiently and lovingly work and patience during the long process to publish
during so many hours of hard work in the last two years. their book.
Now some words to my readers: do not be intimidated
by the challenges of the first chapter. I hope that if you Antoni Bayés de Luna
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Foreword
By Dr Eugene Braunwald
Cardiovascular disease remains the leading cause of important help with this. It is in these parts of the book in
mortality and serious illness in the industrialized world. which the enormous clinical experience of the author
Efforts to improve cardiovascular diagnosis and therapy shines through, since it demonstrates how this very
have never been more vigorous. However, despite the experienced clinician utilizes the electrocardiogram in
development, sophistication, and improvement of a conjunction with the clinical profile and other diagnostic
variety of imaging techniques in cardiovascular diagnosis, techniques in clinical evaluation.
the electrocardiogram is still the most widely employed Professor Bayés de Luna has personally contributed to
laboratory examination of the patient with known or many important areas of clinical electrocardiography,
suspected heart disease. To aid in electrocardiographic including the description of the interesting syndrome of
interpretation, Professor Bayés de Luna has authored this interatrial block with supraventricular arrhythmia and
magnificent fourth edition of Clinical Electrocardiography: he has clarified our understanding and recognition of
A Textbook. This volume, which builds upon its important intra-ventricular block. He has shown how Holter
first three editions, will be enormously helpful to clinical recordings may be used to define patients at high risk of
cardiologists, to internists responsible for the manage- cardiac arrhythmias. These subjects receive appropriate
ment of patients with heart disease, and to cardiology attention.
fellows. In the final analysis, the principal beneficiary of Clinical Electrocardiography is eminently readable and
this excellent book will be the patient with established or successfully takes a middle course between the many
suspected cardiovascular disease. brief manuals of electrocardiography which emphasize
The author, Professor Bayés de Luna, is a master cardi- simple electrocardiographic pattern recognition, and the
ologist who is the most eminent electrocardiographer in lengthy tomes which can be understood only by those
the world today. As a clinician, he views the electrocardio- with a detailed background in electrophysiology. In an
gram as the means to an end – the evaluation of the patient era of multi-authored texts which are often disjointed and
with known or suspected heart disease – rather than as an present information that is repetitive and sometimes even
end in itself. In accordance with this goal, the underlying contradictory, it is refreshing to have a body of informa-
theme is to describe the clinical implications of electrocar- tion which speaks with a single authoritative, respected
diographic findings. The core of this text is in parts 4 and voice. Clinical Electrocardiography is such a book.
5 on clinical arrhythmias and other cardiac conditions
in which the electrocardiogram remains the principal
diagnostic tool. The electrocardiogram is especially Eugene Braunwald, MD
important in the recognition and localization of acute Harvard Medical School
myocardial infarction, and this new edition provides Boston, MA, USA
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Foreword
By Dr Marcelo Elizari
It was an unexpected and pleasant surprise to be invited resonance to a more refined judgment of the electrocardio-
by Professor Antoni Bayés de Luna to write the gram. Hence, the electrocardiographic tracings analyzed
introductory words for the fourth edition of his book on with all this information are extensively and easily
clinical electrocardiography. Reviewing the foreword to understood in a better and more accurate manner. For all
the previous editions makes it clear that the passage of these reasons, Bayés de Luna’s book is worth the highest
time has not undermined the conviction of the comments merit since the reader will not only learn clinical
and considerations expressed by those who were also electrocardiography but will also learn to interpret and
awarded the honor to write the forewords to the Spanish apply it on a scientific basis. Moreover, Professor Bayés de
and English versions of Antonio’s previous books. Luna has not limited himself to reproduce the works of
The greatest impact on the field of electrocardiography others already presented in the literature but has also
came in 1903 with Einthoven’s introduction of the string made original contributions to many subjects of the book.
galvanometer. Thereafter, under the influence of Lewis As a cardiologist, Professor Bayés de Luna has occupied
and Mackenzie in London and of Wenckebach and the most important seats of honour in the world cardiol-
Rothberger in Vienna, the electrocardiogram emerged to ogy and has been a pioneer in the field. Notwithstanding,
provide a valuable tool in the comprehension and he is, above all, a superb teacher and astute researcher
clarification of cardiac arrhythmias. However, following with untiring devotion to the cause of electrocardiogra-
the introduction and development of the clinical use of phy and arrhythmias. Electrocardiography continues to
the chest leads by Wilson began a new era of great be an inexpensive, simple and highly reliable diagnostic
progress in electrocardiography allowing the interpreta- tool for the cardiologist and this well planned book
tion of the contour changes of the electrocardiogram for revives it and enhances the quality of its application.
the diagnosis of physiologic and/or structural abnormali- Since there exist numerous texts, monographs and manu-
ties of the heart under the whole spectrum of cardiac als on electrocardiography, what is then the reason for yet
pathology. Thus, today the electrocardiogram may finally another book? The answer is very simple: there is always
establish a correlation between the damage and the image. place for a good book and the need for a magisterial one
This new edition of clinical electrocardiography will framing the scientific and technologic advances within
immerse physicians and students in the underlying prin- the clinical practice.
ciples and established facts of electrocardiography in a Sir William Osler one said: “To study medicine without
simple and concise way focusing on those aspects of books is to sail an uncharted sea: whilst to study medicine
immediate practical application. In fact, the book pro- only from books is not to go to sea at all.”
vides enough theoretical and practical background to This book has been conceived from a clinician’s
make the reader coherently acquainted with the reason- perspective and offers a balanced approach of great value
ing involved in electrocardiographic interpretation. for students, residents and practitioners and it undoubt-
Antoni Bayés de Luna, in single authorship, has edly deserves to be in every personal and public library.
undertaken the challenge of bringing together the basic
sciences, the clinical and pathologic knowledge, the elec- Marcelo Elizari, MD
trocardiologic techniques, the hemodynamic findings and Head, Cardiology Service
the application of nuclear medicine and nuclear magnetic Hospital Ramos Mejia, Buenos Aires, Argentina
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Recommended Reading
Bayés de Luna A, Cosín J (eds). Cardiac Arrhythmias. Pergamon Grant RP. Clinical Electrocardiography: The spatial vector approach.
Press, 1978. McGraw-Hill, 1957.
Braunwald’s. Heart diseases. A textbook of Cardiovascular Lipman BS, Marrie E., Kleiger RE. Clinical Scalar Electrocardiography,
Medicine. 9th edn. Bonow RO, Mann DL, Zipes, DP, Libby P. 6th edn. Year Book Medical Publishers, 1972.
Elsevier Saunders Pu. 2012. Macfarlane PW, Lawrie TDV (eds). Comprehensive Electrocardiology.
Camm AJ, Lüscher TF, Serruys PW (eds). The ESC Textbook of Pergamon Press, 1989.
Cardiovascular Medicine. Blackwell Publishing, 2006. Piccolo E. Elettrocardiografia e vettocardigorafia. Piccin Editore,
Cooksey JD, Dunn M, Marrie E. Clinical Vectorcardiography and 1981.
Electrocardiography. Year Book Medical Publishers, 1977. Rosenbaum M, Elizari M, Lazzari J. Los hemibloqueos. Editorial
Fisch C, Knoebel S. Electrocardiography of Clinical Arrhythmias. Paidos, 1968.
Futura, 2000. Sodi Pallares D, Bisteni A, Medrano G. Electrocardiografia y
Friedman HH. Diagnostic Electrocardiography and Vectorcardiography, vectorcardiografia deductiva. La Prensa Médica Mexicana,
3rd edn. McGraw-Hill, 1985. 1967.
Fuster V, Walsh RA, Harrington RA (eds). Hurst’s The Heart, Surawicz B, Knilans TK. Chou’s Electrocardiography in Clinical
13th edn. McGraw-Hill, 2010. Practice, 6th edn. WB Saunders Company, 2009.
Gerstch M. The ECG: A two step approach for diagnosis. Springer Tranchesi J. Electrocardiograma normal y patológico. La Medica, 1968.
2004. Wagner GS. Marriott’s Practical Electrocardiography, 10th edn.
Guidelines of AHA/ACC/HRS. Kligfield P, Gettes L, Wagner G, Lippincott Williams & Wilkins, 2001
Mason J, Surawicz B, Rautaharju P, Hancock E, et al. Circulation Zipes D, Jalife J. Cardiac Electrophysiology. From cell to bedside.
2007–2009. WB Saunders. Philadelphia, 2004.
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