Interpretation of Cardiac Arrhythmias: Self-Assessment Approach

576 Pages·2000·24.66 MB·English

by  Zainul Abedin M.D.

Interpretation of Cardiac
Arrhythmias:
Self·Assessment Approach
Developments in Cardiovascular Medicine
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Previous volumes are still available
KLUWER ACADEMIC PUBLISHER5-DORDRECHTIBOSTON/LONDON
Interpretation 01 Cardiac
Arrhythmias:
Sel'-Assessment Approach
by
Zainul Abedin, M.D., FRCP (C), FACC.
Associate Professor of Clinica l Medicine
Texas Tech University Health Sciences Center
El Paso, Texas
Adjunct Associate Professor of Electrical Engineering and
COlnputer Science University of Texas at El Paso
El Paso , Texas
and
Robert Conner, R.N.
....
"
Springer Science+Business Media, LLC
Library of Congress Cataloging-in-Publication Data
Abedin, Zainul, MD.
Interpretation of cardiac arrhythmias : self assessment approach
by Zainul Abedin and Robert Conner.
p. cm. --(Developments in cardiovascular medicine; DICM
220)
Includes index.
ISBN 978-1-4613-7082-6 ISBN 978-1-4615-4607-8 (eBook)
DOI 10.1007/978-1-4615-4607-8
1. Arrhythmia--Diagnosis. 2. Arrhythmia--Diagnosis Examinations,
questions, etc. I. Conner, Robert P. II. Title. III. Series :
Developments in cardiovascular medicine; v. 220.
[DNLM: 1 Arrhythmia--diagnosis Prograrnmed Instruction.
2. Diagnosis, Differential Prograrnmed Instruction.
3. Electrocardiography--methods Prograrnmed Instruction. WG 18.2
A138i 1999]
RC685.A65A24 1999
616. 1' 28--dc2 I
DNLMlDLC 99-16596
for Library ofCongress CIP
Copyright © 2000 Springer Science+Business Media New York
Originally published by Kluwer Academic Publishers in 2000
Softcover reprint ofthe hardcover Ist edition 2000
AII rights reserved. No part of this publication may be reproduced, stored in a
retrieval system or transmitted in any form or by any means, mechanical, photo
copying, recording, or otherwise, without the prior written permission of the
publisher, Springer Science+Business Media, LLC.
Printed on acid-free pap er.
PREFACE
Accurate arrhythmia diagnosis is the goal of this text. Before the clinician can accu
rately classifY the multiple permutations of cardiac rhythm encountered in daily
practice, several essential preconditions must be met. At the most basic level, the
clinician must know the diagnostic criteria for each rhythm. Without a clear under
standing of these criteria, an accurate differential diagnosis is impossible, and without
accurate diagnosis, correct intervention is a mere matter of chance.
A second precondition of accurate rhythm diagnosis is an understanding of the
mechanism if arrhythmias. Not uncommonly, two or more arrhythmic mechanisms
coexist, confronting the clinician with a baffiing mixture of apparently unrelated
complexes and intervals. Without an understanding of the various arrhythmic mech
anisms, simple and complex, the tangled skein of data can never be unraveled.
Finally, accurate arrhythmia diagnosis depends on skill attained through practice.
The competent electrocardiographer combines the skills of precise measurement and
rational application of logic with broad theoretical knowledge. The pleasure of elec
trocardiography is the pleasure of seeing through the surface appearance to the inner
workings.
This text, which presupposes no prior knowledge of arrhythmias, progresses from
the basic to the complex both from chapter to chapter and within individual chap
ters. The didactic sections focus extensively on the mechanism, of arrhythmias, using
laddergrams and other diagrammatic devices to help the student visualize what is
happening within the cardiac conduction system. The extensive self-assessment
sections enable students to apply critical skills and test their grasp of the diagnostic
criteria.
Many complex arrhythmias, such as dual pathways, double junctional rhythm,
multilevel atrioventricular block, and concealed reentry are included in this text
specifically to disabuse the student of any notion of the conduction system as mere
"wiring." Some students will find that these topics ease the transition from the scalar
ECG to the multichannel records necessary to the specialist in electrophysiology.
ZA
RC
In loving memory of my parents
and
To my wife Karuna
and
My children Moeen, Sakena, and Zameer
ZA
To my mother
RC
Aclroowledgement
We gratefully acknowledge the expert editorial help of Melissa A. Ramondetta,
Laura Walsh, Salena Hastings and other members of the Kluwer editorial and
publishing team. Z.A. & R.C.
TABLE OF CONTENTS
Preface v
1. The Electrocardiogram 1
Anatomy of the conduction system
The electrocardiogram 4
ECG paper and rate calculation 10
2. The Sinus Rhythms 11
Normal sinus rhythm 11
Sinus arrhythmia 12
Accelerated atrioventricular conduction 12
Sinus tachycardia 12
Sinus bradycardia 12
Wandering atrial pacemaker 14
Self-assessment section: Chapter 2 15
Answer key 22
3. Axis Determination 23
Lead systems 23
Axis determination 24
Self-assessment section: Chapter 3 31
Answer key 42
4. The Atrial Arrhythmias 43
Premature atrial complexes 43
Ectopic atrial rhythm 47
Atrial fibrillation 47
viii Table of Contents
Atrial flutter 50
Atrial tachycardia 53
Multifocal atrial tachycardia 53
Posttachycardia sinus depression 55
Differential diagnosis of supraventricular tachycardias 55
References 55
Self-assessment section: Chapter 4 57
Answer key 69
5. Atrioventricular Block 71
Prolonged PR interval (first-degree AV block) 71
Second-degree AV block 73
Type I (Wenckebach) second-degree AV block 73
Skipped P waves 80
First-degree AV block and nonconducted P waves 80
Type II (Mobitz II) second-degree AV block 80
Second-degree AV block with 2:1 and 3:1 conduction rates 82
High-grade (advanced) second-degree block 84
Paroxysmal AV block 87
Third-degree AV block 90
Ventriculophasic sinus arrhythmia 93
Block-acceleration dissociation 93
References 96
Self-assessment section: Chapter 5 97
Answer key 115
6. Multilevel Atrioventricular Block 117
Wenckebach conduction of supraventricular tachycardia 117
Maintenance of even conduction ratios 119
Wenckebach periods of alternate beats 122
Wenckebach conduction at successive levels 132
References 132
7. Sick Sinus Syndrome 133
Sinoatrial exit block 133
Second-degree SA block 134
Sinus arrest 140
Tachycardia-bradycardia syndrome 142
Sinus node suppression 142
References 149
Self-assessment section: Chapter 7 151
Answer key 160
8. Intraventricular Conduction Defects 161
Fascicular block 162
Bundle branch block 163
Bifascicular block 165
Bilateral bundle branch block 167
Aberrant ventricular conduction 167
Wenckebach periods in bundle branches 170
Self-assessment section: Chapter 8 175
Answer key 197
9. The Junctional Rhythms 199
Junctional extrasystoles and rhythms 201
Table of Contents ix
Idiojunctional rhythm 203
Double junctional rhythm 203
Self-assessment section: Chapter 9 209
Answer key 222
10. Escape and Capture 223
Escape beats and rhythms 223
Capture beats 234
References 239
Self-assessment section: Chapter 10 241
Answer key 254
11. The Echo Phenomenon and Dual Pathways 255
The echo phenomenon (reciprocation) 255
Different PR and RP intervals as a manifestation of dual pathways 259
Dual ventricular response as a manifestation of dual pathways 264
12. The Wolff-Parkinson-White Syndrome 265
Localization of accessory pathway using the surface ECG 270
Self-assessment section: Chapter 12 277
Answer key 297
13. Supraventricular Reentrant Tachycardia 299
Atrioventricular nodal reentry tachycardia (AVNRT) 300
Bypass tract-mediated tachycardia (BTMT) 303
Diffential diagnosis: AVNRT versus BTMT 304
P:QRS relationship and P wave morphology 304
Initiation of the tachycardia 309
Electrical alternans 309
Atrioventricular block 309
Decrease of rate with QRS widening 311
Maneuvers and drugs 312
ST segment depression during tachycardia 313
Multiple coexisting pathways 313
Permanent junctional reciprocating tachycardia (PJRT) 313
Mahaim tachycardia 316
Interventions 318
Sinoatrial reentry tachycardia 318
References 320
Self-assessment section: Chapter 13 321
Answer key 356
14. Concealed Conduction and Concealed Extrasystoles 359
Concealed atrioventricuar reentry complicating wenckebach cycles 367
Transseptal concealed conduction perpetuating aberrant ventricular conduction 371
Concealed conduction suppressing impulse formation 373
Concealed junctional extrasystoles 375
References 381
15. The Ventricular Arrhythmias 383
Ventricular extrasystoles 384
Thr rule of bigeminy 386
Monomorphic ventricular tachycardia 386
Differential diagnosis of wide-QRS tachycardias 389
Width of the QRS complex 389
x Table of Contents
QRS axis 389
Atrioventricular dissociation 390
Ventricular fusion and capture beats 394
QRS morphology 395
Ventricular tachycardia with right bundle branch morphology 398
Ventricular tachycardia with left bundle branch morphology 401
Ventricular tachycardia versus aberrancy 403
Polymorphic ventricular tachycardia 404
Congenital long QT syndromes (CQTS) 405
Catecholaminergic polymorphic VT 406
Miscellaneous syndromes 406
The Brugada syndrome 406
Ventricular tachycardia due to bundle branch reentry 409
Arrhythmogenic right ventricular dysplasia 409
Right ventricular outflow tract (RVOT) ventricular tachycardia 410
Idiopathic left ventricular tachycardia 410
Bidirectional ventricular tachycardia 410
Accelerated idioventricular rhythm 412
Ventricular fibrillation 413
Etiology of ventricular fibrillation 413
References 415
Self-assessment section: Chapter 15 417
Answer key 456
16. Exit Block 459
17. Parasystole 465
Self-assessment section: Chapter 17 475
Answer key 511
18. Electronic Pacemakers 515
Basic functional parameters 516
NBG Pacemaker Code 517
Pacemaker intervals 519
Pacemaker malfunction 522
Diagnosis of pacemaker malfunction 523
Altered pacemaker artifact (spike) 523
QRS morphology during pacing 523
Prolonged spike-to-QRS interval 525
Undersensing 525
Oversensing 525
Failure to pace 526
Loss of capture 526
Basic pacemaker timing cycles 527
Dual chamber pacemaking timing cycles 528
Self-assessment section: Chapter 18 531
Answer key 567
Index 571