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https://t.me/MedicalEbooksLibrary https://t.me/MedicalEbooksLibrary The Only EKG BOOK You’ll Ever Need NINTH EDITION MALCOLM S. THALER, M.D. Physician, Internal Medicine, One Medical Clinical Instructor in Medicine, Weill Cornell Medical College Medical Staff, New York Presbyterian Hospital New York, New York https://t.me/MedicalEbooksLibrary Executive Editor: Rebecca Gaertner Senior Product Development Editor: Kristina Oberle Production Project Manager: Marian Bellus Marketing Manager: Rachel Mante Leung Design Coordinator: Holly McLaughlin Senior Manufacturing Coordinator: Beth Welsh Prepress Vendor: SPi Global Ninth edition Copyright © 2019 Wolters Kluwer © 2015 by Wolters Kluwer; 1988 by Lippincott Williams & Wilkins; © 1995 by J.B. Lippincott; © 1999, 2002, 2007, 2010, 2012 by Lippincott Williams & Wilkins All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer Health at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China Library of Congress Cataloging-in-Publication Data Names: Thaler, Malcolm S., author. Title: The only EKG book you’ll ever need / Malcolm S. Thaler. Description: Ninth edition. | Philadelphia : Wolters Kluwer, [2019] | Includes index. Identifiers: LCCN 2017053867 | eISBN 9781975106072 Subjects: | MESH: Electrocardiography | Heart Diseases—diagnosis | Case Reports Classification: LCC RC683.5.E5 | NLM WG 140 | DDC 616.1/207547—dc23 LC record available at https://lccn.loc.gov/2017053867 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals' examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer's package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contradictions, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. LWW.com Dedication For Nancy, Ali, Jon, and Tracey too–as well as for everyone toiling in the health care profession, trying to make people’s lives happier and healthier. Preface The torrid pace of technologic and scientific evolution shows no signs of letting up, and clinical medicine is both its beneficiary and, conspicuously, its victim, too, as we seem to have less and less time to actually spend with our patients. It is therefore comforting to know that at least one old friend still stands tall—the EKG. Almost 30 years have passed since the first edition of this little book, and nothing has yet supplanted the EKG as the essential tool for diagnosing many cardiac disorders (and many noncardiac ones as well). Does your patient have chest pain?—get an EKG! Does your patient have palpitations?—get an EKG! Syncope or dizziness?—you get the point. These three decades have not dimmed the principles outlined in the preface to the first edition: This book is about learning. It’s about keeping simple things simple, and complicated things clear, concise and, yes, simple, too. It’s about getting from here to there without scaring you to death, boring you to tears, or intimidating your socks off. It’s about turning ignorance into knowledge, knowledge into wisdom, and all with a bit of fun. If I were writing this today, I would probably reword that business about the socks, but the sentiments remain and are, I hope, ones you share. New material has been added as new developments—and there have been many—have called for it, and everything is always discussed within its proper clinical context by putting you, the reader, right in the middle of real life situations. EKG’s are not used in isolation; they are just one piece—albeit an important piece—of the puzzle that every patient presents and that you and I have to figure out over and over again. I want to offer a very special thanks to Dr. Adam Skolnick, M.D., Associate Professor of Medicine, Leon H. Charney Division of Cardiology, NYU Langone Medical Center, whose keen editorial eye, incisive analysis, and unsurpassed expertise are the best guarantee that you will be reading the most current, clear, and accurate text that anyone could hope for. And allow me to add a shout out to Dr. Jeffrey Lorin, Assistant Professor of Medicine at NYU Medical Center, who graciously opened up his world-class collection of EKG’s so that we all could benefit. A special thank you as always to the wonderful folks at Wolters Kluwer—let me give a very personal standing ovation to Kristina Oberle and Rebecca Gaertner—who always produce a beautiful, polished, limpid book (and have the good sense to edit out words like limpid when words such as clear and readable are far more serviceable and, well, limpid). They make every edition a joy to work on. For those of you picking up this book for the first time—as well as for those of you coming back for a return visit—I hope The Only EKG Book You Will Ever Need provides you with everything you need to start reading EKG’s quickly and accurately. Malcolm S. Thaler, M.D. Contents Getting Started Chapter 1 The Basics Electricity and the Heart The Cells of the Heart Time and Voltage P Waves, QRS Complexes, T Waves, and Some Straight Lines Naming the Straight Lines Summary: The Waves and Straight Lines of the EKG Making Waves The 12 Views of the Heart A Word About Vectors The Normal 12-Lead EKG Summary: Orientation of the Waves of the Normal EKG Some Really Important Stuff That You May Be Wondering: Part 1: Why Not Just Let the Computer Do It? Some Really Important Stuff That You May Be Wondering: Part 2: How Do I Get the Goop Off My Patient’s Chest Once the EKG Is Finished? Coming Attractions Chapter 2 Hypertrophy and Enlargement of the Heart A Few Introductory Remarks Definitions Axis Summary: Axis Axis Deviation, Hypertrophy, and Enlargement Atrial Enlargement Summary: Atrial Enlargement Ventricular Hypertrophy Secondary Repolarization Abnormalities of Ventricular Hypertrophy Summary: Ventricular Hypertrophy CASE 1 CASE 2 Chapter 3 Arrhythmias The Clinical Manifestations of Arrhythmias Why Arrhythmias Happen Rhythm Strips How to Determine the Heart Rate From the EKG The Five Basic Types of Arrhythmias Arrhythmias of Sinus Origin Summary: Arrhythmias of Sinus Origin Ectopic Rhythms Reentrant Rhythms The Four Questions Supraventricular Arrhythmias Summary: Supraventricular Arrhythmias Ventricular Arrhythmias Summary: Ventricular Arrhythmias Supraventricular Versus Ventricular Arrhythmias Summary: Ventricular Tachycardia Versus Supraventricular Tachycardia With Aberrancy Electrophysiology Studies (EPS) Implantable Defibrillators External Defibrillators CASE 3 CASE 4 CASE 5 Chapter 4 Conduction Blocks What Is a Conduction Block? AV Blocks Summary: AV Blocks Bundle Branch Block Summary: Bundle Branch Block Hemiblocks Combining Right Bundle Branch Block and Hemiblocks Blocks That Underachieve The Ultimate in Playing With Blocks: Combining AV Blocks, Right Bundle Branch Block, and Hemiblocks Pacemakers CASE 6 CASE 7 CASE 8 Chapter 5 Preexcitation Syndromes What Is Preexcitation? Wolff–Parkinson–White A Short PR Interval Without a Delta Wave Why Do We Care About Preexcitation? Summary: Preexcitation CASE 9 Chapter 6 Myocardial Ischemia and Infarction Stable Angina and Acute Coronary Syndromes How to Diagnose a Myocardial Infarction ST-Segment Elevation Myocardial Infarctions (STEMIs) Summary: The EKG Changes of an Evolving STEMI Localizing the Infarct Non–ST-Segment Myocardial Infarctions (non-STEMIs) Takotsubo Cardiomyopathy Angina Without Infarction Sorting Out the Different Ischemic Syndromes Limitations of the EKG in Diagnosing an Infarction Stress Testing CASE 10 CASE 11