The ECG Made Practical

343 Pages·2019·13.184 MB·English

by  John R. Hampton

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2015v1.0
The
ECG
Made Practical
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The
ECG
Made Practical
SEVENTH EDITION
JOHN HAMPTON
DM MA DPhil FRCP FFPM FESC
Emeritus Professor of Cardiology, University of Nottingham, UK
DAVID ADLAM
BA BM BCh DPhil FRCP FESC
Associate Professor of Acute and Interventional Cardiology and Honorary
Consultant Cardiologist, University of Leicester, Leicester, UK
EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY 2019
© 2019 Elsevier Ltd. All rights reserved.
First edition 1986
Second edition 1992
Third edition 1997
Fourth edition 2003
Fifth edition 2008
Sixth edition 2013
Seventh edition 2019
The right of John Hampton and David Adlam to be identified as author(s) of this work has been asserted by them in
accordance with the Copyright, Designs and Patents Act 1988.
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may
be noted herein).
Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any
information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences,
in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no
responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as
a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or
ideas contained in the material herein.
ISBN 978-0-7020-7460-8
978-0-7020-7461-5
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
The
publisher’s
Content Strategist: Laurence Hunter
policy is to use
Content Development Specialist: Fiona Conn
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Contents
Preface vii
12-lead ECGs ix
1. The ECG in healthy people 1
2. The ECG in patients with palpitations and syncope:
initial assessment 57
3. The ECG in patients with palpitations and syncope:
ambulatory ECG monitoring 85
4. The ECG when the patient has a tachycardia 93
5. The ECG when the patient has a bradycardia 147
6. The ECG in patients with chest pain 195
7. The ECG in patients with breathlessness 255
8. The effects of other conditions on the ECG 283
9. Conclusions: four steps to making the most of the
ECG 313
Index 317
v
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Preface
What to expect of this book understand them so there is a series of changes in the
text compared with previous editions: for example,
This book is the seventh edition of The ECG in Practice,
there is more focus on ambulatory monitoring and
but we have changed the title to The ECG Made Practical
newer monitoring devices and developments in pacing
to emphasize its relationship to The ECG Made Easy
systems and defibrillators are described. We have made
We assume that the reader of this book will have the
a clearer link between the ECGs of myocardial infarc-
level of knowledge of the ECG that is contained in The
tion, coronary anatomy and the site of myocardial
ECG Made Easy. The ECG is indeed easy in principle, but
injury. To make room for these changes, and to give
the variations in pattern seen both in normal people and
more space to ECG interpretation, there is now less
in patients with cardiac and other problems can make the
focus on patient management.
ECG seem more complex than it really is. This book con-
The new edition of the third title in the series is being
centrates on these variations, and contains several exam-
published simultaneously and again we have changed the
ples of each abnormality. It is intended for anyone who
title, from 150 ECG Problems to 150 ECG Cases to empha-
understands the basics, but now wants to use the ECG to
size the central place of the patient rather than the ECG.
its maximum potential as a clinical tool.
This new edition is divided into two sections, one con-
The ECG is not an end in itself, but is an extension of
taining numerous examples of ‘everyday’ ECGs which are
the history and physical examination. Patients do not visit
suitable for those who have mastered The ECG Made Easy,
the doctor wanting an ECG, but come either for a health
and the other including more esoteric and difficult ECGs
check or because they have symptoms. Therefore this
which provides more examples than can be included the
book is organized according to clinical situations, and the
this new edition of The ECG Made Practical. Those who
chapters cover the ECG in healthy subjects and in patients
want to practice their skills after reading The ECG Made
with palpitations, syncope, chest pain, breathlessness or
Practical will find their challenge in the fifth edition of 150
non-cardiac conditions. To emphasize that the ECG is
ECG Cases.
part of the general assessment of a patient, each chapter
begins with a brief section on history and examination.
What to expect of the ECG
This seventh edition continues the philosophy of
its predecessors in that the patient is considered more The ECG has its limitations. Remember that it provides a
important than the ECG. However, the ECG is a vital picture of the electrical activity of the heart, but gives only
part of diagnosis and, increasingly, influences treat- an indirect indication of the heart’s structure and func-
ment. Electrical devices of various sorts are standard tion. It is, however, invaluable for assessing patients whose
treatment in cardiology, and patients with such devices symptoms may be due to electrical malfunction in the
commonly present with non-cardiological problems. heart, especially patients with conduction problems and
Those who are not specialists in cardiology need to those with arrhythmias.
vii
Preface
In healthy people, finding an apparently normal it is not a good way of diagnosing lung disease or pul-
ECG may be reassuring. Unfortunately, the ECG can be monary embolism. Finally it must be remembered that
totally normal in patients with severe coronary disease. the ECG can be quite abnormal in a patient with a variety
Conversely, the range of normality is such that a healthy of non-cardiac conditions, and one must not jump to
subject may quite wrongly be labelled as having heart the conclusion that an abnormal ECG indicates cardiac
disease on the basis of the ECG. Some ECG patterns pathology.
that are undoubtedly abnormal (e.g. right bundle branch
Acknowledgements
block) are seen in perfectly healthy people. It is a good
working principle that it is the individual’s clinical state In this seventh edition of The ECG Made Practical we have
that matters, not the ECG. been helped by many people. In particular, we are grate-
When a patient complains of palpitations or syncope, ful to our development editor, Fiona Conn, for her enor-
the diagnosis of a cardiac cause is only certain if an ECG mous attention to detail that led to many improvements
is recorded at the time of symptoms – but even when in the text. We are also grateful to Laurence Hunter and
the patient is symptom-free, the ECG may provide a his team at Elsevier for their encouragement and patience.
clue for the prepared mind. In patients with chest pain As before, we are grateful to many friends and colleagues
the ECG may indicate the diagnosis, and treatment can who have helped us to find the wide range of examples
be based upon it, but it is essential to remember that of normal and abnormal ECGs that form the backbone of
the ECG may remain normal for a few hours after the the book.
onset of a myocardial infarction. In breathless patients a
totally normal ECG probably rules out heart failure, but JH, DA
viii