SECOND EDITION LEARN TO EFFECTIVELY INTERPRET VIRTUALLY EVERY ECG FERRY YOU’RE LIKELY TO ENCOUNTER IN CLINICAL PRACTICE – ECG IN TEN BRIEF LESSONS E C T he only review book to offer full-sized ECGs G throughout (simulating how they appear on NEW TO THE SECOND EDITION I tests and in actual practice), this sourcebook N • Inclusion of the latest American College of is the most sought-after ECG review anywhere, Cardiology (ACC) guidelines trusted by cardiology fellows, internal medicine • Selection of randomECGs after Day 10 for 1 residents, medical students, and health-related additional review 0 professionals alike. ECG IN TEN DAYSis based on the • A brand-new glossary with key terms, which author’s popular ten-day review course, and are also bolded within the text D features a unique step-by-step approach, crystal- • Short appendix that includes formal criteria 10.875 clear vector images, plus practice EDB strips to for various ECG diagnoses A build confidence and fine-tune clinical skills. • Consolidated chapters 2 and 3 for a more Y cohesive look at super ventricular arrhythmias In these pages, you’ll find essential information S • Reorganized chapters that streamline the on everything from SA & AV nodal conduction content on Day 6, and help ensure a more abnormalities, to mechanisms of arrhythmias and efficient, manageable review of the material In 10 Days electronic pacemakers. Also included is an answer sheet similar to the one encountered on board exams. • Learn how to interpret ECGs in the shortest possible time SECOND EDITION • 120+ full-sized ECGs with interpretations • Based on the author’s popular ECG review course • Logically organized outline format facilitates retention ISBN-13: 978-0-07-146562-5 • Now includes ACC guides ISBN-10: 0-07-146562-6 David R. Ferry 27/32 8.5 Softcover trim: 8-1/2 x 10-7/8 Color: 4 color process final bulk: .842 (27/32 spine) Lam: GBC Layflat glossy Ferry_FM.qxd 10/10/06 12:31 PM Page i ECG in 10 Days David R. Ferry, MD, FACC Chief, Cardiology Section Loma Linda VA Healthcare System Associate Professor of Medicine Loma Linda University School of Medicine Loma Linda, California NEW YORK CHICAGO SAN FRANCISCO LISBON LONDON MADRID MEXICO CITY MILAN NEW DELHI SAN JUAN SEOUL SINGAPORE SYDNEY TORONTO Copyright © 2013 by The McGraw-Hill Companies, Inc. All rights reserved. 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As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. Ferry_FM.qxd 10/10/06 12:31 PM Page iii This book is dedicated to my good friend, mentor, and role model, Dr. Glenn L. Foster, cardiologist and former Chief of Medicine at the Loma Linda VA Healthcare System. He taught me that patience, humanity, dignity, precision, integrity, and spirituality were essential to the practice of medicine and the living of life. This page intentionally left blank Ferry_FM.qxd 10/10/06 12:31 PM Page v Table of Contents Preface vii Acknowledgments ix Suggestions for Using This Book xi Day 1 The Basics 1 Day 2 Chamber Abnormalities and Intraventricular Conduction Defects 37 Day 3 SA and AV Nodal Conduction Abnormalities 94 Day 4 Ischemia and Infarction 151 Day 5 Reentrant Arrhythmias 194 Day 6 Ectopic Arrhythmias and Triggered Activity 246 Day 7 Extrasystoles and Preexcitation Syndromes 287 Day 8 The Differential Diagnosis of Wide-QRS Tachycardias 333 Day 9 Medication and Electrolyte Effects; Miscellaneous Conditions 379 Day 10 Electronic Pacemakers 444 v This page intentionally left blank Ferry_FM.qxd 10/10/06 12:31 PM Page vii Preface This book originally arose from our commitment to teach senior medical students how to interpret electrocardiograms in two weeks, or ten work- ing days. The School of Medicine, in its wisdom, had chosen that interval for us, and we were forced to adapt to its mandate. We had 10 to 15 stu- dents in our class every four weeks for the entire academic year. We quickly realized that we needed to establish specific topics for each day so that, regardless of which faculty members were available, there was a consistent method used. We also decided on a set of sample ECGs to use each day. I found myself repeatedly drawing the same illustrations, charts, and dia- grams, so I eventually put together the rudiments of this text into a handout. This effort was well received by medical students, residents from Internal Medicine, Family Practice, and Preventive Medicine, and nurses and techni- cians. I was subsequently encouraged to publish this material, and the editors at McGraw-Hill were gracious enough to accommodate me. Since publication of the first edition, several things have become obvi- ous, particularly that I needed to provide many more sample ECGs for prac- tice, both at the end of the chapters and a random sample at the end of the text. Therefore, there are now 20 ECGs at the ends of Chapters 2–9 and 100 at the end, bringing the total practice tracings to 280, far more than any other book. I needed to update several figures and add many more to accommo- date advances in electrocardiography and make some concepts easier to understand. It was obvious that I needed to divide the contents of Day 5 into two chapters, therefore necessitating compression of Days 2 and 3 into one chapter. I also decided to use full 12 lead ECGs instead of rhythm strips to illustrate the majority of concepts, since it would be in this format that prac- titioners would encounter these tracings. Finally, I decided to use a system I call “call-outs” on the sample ECGs, in which key portions of the tracing are identified by circles and are then enlarged and commented on in the top margin. There have also been major advances in computer imaging, processing, and storage since the first text. In this edition, all of the illustrations were drawn on an Apple Macintosh G5 computer using Adobe PhotoShop CS2 vii Ferry_FM.qxd 10/10/06 12:31 PM Page viii viii Preface and a Wacom graphics tablet. The ECGs were scanned at 600 dpi for clarity even when magnified in the call-outs. It is my hope that my readers will enjoy this text as much as I did in preparing it and in teaching the concepts. David R. Ferry, MD Ferry_FM.qxd 10/10/06 12:31 PM Page ix Acknowledgments I would like to thank my colleagues at the Loma Linda VA Healthcare Center, Drs. Geir P. Frivold, Gary P. Foster, Alan K. Jacobson, Helme Silvet, Patricia M. Applegate, and Paul A. Levine, for their constant encouragement, suggestions, and corrections. Many of the features of this text are the result of quiet, continuous gentle pressure applied by my friend Geir Frivold. The medical students made countless suggestions about ways to improve the first edition and told me what worked and what did not. My wife, Dr. Linda H. Ferry, was her usual source of wis- dom and inspiration. My editor at McGraw-Hill, Quincy McDonald and project manager at ITC, Gita Raman, patiently worked with me to keep the book on schedule and the quality high. Finally, I will never forget my teachers and mentors from my fellowship days, Drs. Michael H. Crawford and Robert A. O’Rourke. ix