ECGs by Example For Elsevier Senior Commissioning Editor : Laurence Hunter Development Editor : Carole McMurray Project Manager : Cheryl Brant Designer : Charles Gray Illustration Manager: Gillian Richards ECGs by Example Dean Jenkins Stephen Gerred MB BCh DipMedEd FRCP MBChB FRACP Honorary Consultant Physician Royal Cornwall Hospital Truro UK Consultant Gastroenterologist Middlemore Hospital Auckland New Zealand THIRD EDITION EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2011 © 2011 Elsevier Ltd All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) First edition 1997 Second edition 2005 Third edition 2011 ISBN 978-0-7020-4228-7 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notices Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary Printed in China Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability 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 v CONTENTS ACKNOWLEDGEMENTS Introduction vii An approach to the ECG Acknowledgements x viii 31 Polymorphic ventricular tachycardia 65 32 Polymorphic ventricular tachycardia – ‘torsade de pointes’ 67 33 Ventricular flutter 69 34 Ventricular fibrillation (VF) 71 Section Supraventricular rhythms Normal sinus rhythm Normal sinus rhythm with a normal U wave Sinus arrhythmia (irregular sinus rhythm) Sinus tachycardia Sinus bradycardia 11 Atrial bigeminy 13 Atrial trigeminy 15 Ectopic atrial rhythm 17 Multifocal atrial tachycardia 19 10 Atrial fibrillation 21 11 Atrial fibrillation with rapid ventricular response 23 12 Atrial fibrillation and bundle branch block 25 13 Atrial flutter 27 14 Atrial flutter with 2:1 AV block 29 15 Atrial flutter with variable AV conduction 31 16 Accelerated junctional rhythm 33 17 Junctional bradycardia 35 18 Paroxysmal SVT – AV nodal re-entry tachycardia 37 19 Paroxysmal SVT – AV reciprocating tachycardia (orthodromic) 39 20 AV reciprocating tachycardia (antidromic) 41 21 Wolff–Parkinson–White syndrome with atrial fibrillation 43 22 Supraventricular tachycardia with aberrant conduction 45 23 Sick sinus syndrome 47 Section Ventricular rhythms 24 25 26 27 Ventricular premature beat (VPB) 51 Ventricular bigeminy 53 Accelerated idioventricular rhythm 55 Ventricular tachycardia – atrioventricular dissociation 57 28 Ventricular tachycardia – capture and fusion beats 59 29 Ventricular tachycardia – morphology of VPB 61 30 Ventricular tachycardia – myocardial infarction 63 Section Bundle branch block 35 36 37 38 39 40 41 Right bundle branch block (RBBB) 75 Incomplete right bundle branch block 77 Left bundle branch block (LBBB) 79 Incomplete left bundle branch block 81 Left anterior hemiblock 83 Left posterior hemiblock 85 Right bundle branch block with left anterior hemiblock (bifascicular block) 87 42 Right bundle branch block with left anterior hemiblock and long PR interval (‘trifascicular’ block) 89 43 Phasic aberrant ventricular conduction 91 Section Heart block 44 First degree heart block 95 45 Second degree heart block – Mobitz type or Wenckebach AV block 97 46 Second degree heart block – Mobitz type 99 47 Second degree heart block – 2:1 AV block 101 48 Second degree heart block – high grade 103 49 Third degree heart block – wide complex escape 105 50 Third degree heart block – narrow complex escape 107 51 Third degree heart block and atrial fibrillation 109 Section Pacemakers 52 Ventricular pacemaker 113 53 Dual chamber pacing (AV sequential pacing) 115 54 Problems with pacemakers – failure to sense 117 55 Problems with pacemakers – failure to capture 119 56 Polymorphic VT with cardioversion and pacing by an implantable cardioverter defibrillator (ICD) 121 vi Section Ischaemic heart disease 57 Myocardial ischaemia – ST depression 125 58 Myocardial ischaemia – T wave inversion 127 59 Myocardial ischaemia – non-specific changes 129 60 Acute extensive anterior myocardial infarction 131 61 Acute anterolateral myocardial infarction 133 62 Acute anteroseptal myocardial infarction 135 63 Acute ‘high’ lateral myocardial infarction 137 64 Acute inferior myocardial infarction 139 65 Very early acute inferior myocardial infarction 141 66 Acute right ventricular infarction 143 67 Acute posterior myocardial infarction 145 68 Acute anterior myocardial infarction in the presence of left bundle branch block 147 Section Hypertrophy patterns 69 70 71 72 73 Right atrial abnormality (P-pulmonale) 151 Left atrial abnormality (P-mitrale) 153 Biatrial hypertrophy 155 Right ventricular hypertrophy (RVH) 157 Left ventricular hypertrophy (LVH) - limb lead criteria 159 74 Left ventricular hypertrophy (LVH) - chest lead criteria 161 75 Biventricular hypertrophy 163 Section Systemic disorders and drug effects 76 Hypothermia 167 77 Hyperkalaemia (subtle ECG changes) 78 Hyperkalaemia (extreme ECG features) 171 79 Hypokalaemia 173 80 Hypocalcaemia 175 81 Hypercalcaemia 177 82 Digoxin (digitalis) effect 179 83 Tricyclic antidepressant overdose Section Technical issues 84 Electrical interference 185 85 Skeletal muscle interference 187 86 Regular skeletal muscle interference 189 87 ‘Technical’ dextrocardia 191 88 Misplaced chest leads 193 Section 10 Miscellaneous 89 90 91 92 93 94 95 96 97 98 99 100 101 102 169 181 The athletic heart 197 Acute pulmonary embolus (PE) 199 Cardiac amyloidosis 201 Arrhythmogenic right ventricular dysplasia (ARVD) 203 Left ventricular aneurysm 205 Acute pericarditis 207 Pericardial effusion 209 Pericardial effusion with electrical alternans 211 Wolff–Parkinson–White syndrome (1) (ventricular pre-excitation) 213 Wolff–Parkinson–White syndrome (2) 215 Lown–Ganong–Levine syndrome 217 Congenital long QT syndrome (LQTS) 219 Dextrocardia 221 Auxiliary (heterotopic or ‘piggyback’) heart transplant 223 Index 225 vii INTRODUCTION ACKNOWLEDGEMENTS ‘Real ECGs on the ward never look like the diagrams I’ve seen in textbooks.’ ‘I’ve read and understood the ‘The ECG Made Easy’ but I still get lost when confronted with the real thing.’ These are typical of the comments we have heard when trying to teach electrocardiography to medical students, nurses, paramedics, or junior doctors They are the reason why we have written this book They are the reason why this book is different If you’ve read and understood an introductory ECG book, such as John Hampton’s “The ECG Made Easy”, but still get fazed by the real thing when it confronts you in the Emergency Department or on the ward, then this book is for you All the examples are actual ECG recordings as they would appear in everyday practice Each recording is at standard speed and size; 25 mm/sec, cm/mV We have endeavoured to include as many as possible of the commonly encountered abnormalities as well as some less common ECG findings which are of clinical importance This third edition sees the addition of several new cases as well as a number of updated cases The content is based on a joint report by the American College of Physicians, American College of Cardiology and the American Heart Association (Fish C et al 1995 Clinical competence in electrocardiography Journal of the American College of Cardiologists 25(6): 1465-1469) This report lists the electrocardiographic features that a competent physician should be able to recognise How to use this book Each individual case consists of a full size ECG with a brief sentence summarising the patient’s clinical presentation Below each ECG there is a critique starting with a list of diagnostic features, then a full report of the ECG and any other clinical details that may be important On most pages there is also a box of common causes or associations There are also a number of relevant radiological images You may wish to read the book as a text, use it to test yourself and others, or simply use it for reference purposes Becoming competent at interpreting real ECGs depends on seeing as many examples as possible and discussing them with a senior colleague You may wish to use this book as a guide to building a comprehensive ECG collection of your own 2010 Dean Jenkins Stephen Gerred viii AN APPROACH TO THE ECG We are not going to expand a method for the systematic interpretation of the electrocardiogram as this has been done in many other ECG books This book is about the ECG in the context of everyday practice giving examples of how it appears in the clinic or on the ward round We’d like to share a practical approach to the ECG in clinical practice so that it can be used to its best advantage First you need to remember to use the ECG It is a tool that can be overlooked especially when it has been taken, as a matter of routine, by someone else in the clinical team before you have even seen the patient As a bedside instrument that is available in many healthcare settings it can be very useful in making a clinical diagnosis Situations where it may be overlooked are those that are not obviously cardiac Look at the systemic disorders and drug effects [Section 8] and the miscellaneous [Section 10] parts in this book for many example of how an ECG can help clinch a diagnosis or management plan In general it is a tool that has high specificity but low sensitivity The ECG often confirms a diagnosis but it is not soo good at excluding a diagnosis This is discussed in particular in the section on hypertrophy patterns [Section 7] Screening for left ventricular hypertrophy is better achieved by the use of echocardiography however, where the diagnostic criteria are present on the ECG, it can identify cases accurately The ECG is the best bedside tool for cardiac arrhythmias and the investigation of suspected acute coronary syndromes but even in these cases remember to request an ECG, or record one yourself and, importantly, multiple copies of the ECG when the clinical circumstances change, a procedure is performed, or the existing ECGs are not diagnostic It is better to have multiple ECGs that can be archived in the patient’s notes than to be wishing that one had been taken at a certain point in the past In the acute setting you need to be tactical with the use of the ECG Sometimes it is better to have a poor recording, or just the printout from a monitoring chest lead [page 67 for torsade des pointes VT], when other clinical circumstances prevent the careful recording of a 12-lead ECG Rhythm and morphology aren’t always necessary to have at the same time Acute medicine is often about judging priorities Assuming that a good 12-lead recording is required then the best way to prepare for interpretation is to start by taking the recordings yourself They don’t take long to and, with practice, you can take the history from the patient as your setting up the electrodes saving time and building a rapport with your patient ix Become familiar with where the wires are attached: – both ankles and both wrists – V1 right 4th intercostal space at the sternum – V2 left 4th intercostal space at the sternum – V3 halfway between V2 and V4 – V4 at the apex beat (5th intercostal space, midclavicular line) – V5 anterior axilliary line (same level as V4) – V6 mid axilliary line (same level as V4) See the section on technical issues [Section 9] for details of common problems that may occur with the recording of an ECG Mid clavical line Angle of Louis Anterior axillary line Mid axillary line aVR aVL aVF I II III An 11-year-old boy with bouts of breathlessness CASE 98 V4 V5 V6 V1 V2 V3 214 Left posteroseptal (type A) Right lateral (type B) Left lateral (type C, commonest) Right posteroseptal Anteroseptal V1 +ve –ve +ve –ve –ve Localising the accessory pathway V2 +ve –ve +ve –ve –ve QRS axis left left right left normal This recording is from the same patient shown in the supraventricular rhythms section (WPW orthodromic AV reciprocating tachycardia; CASE 19) CLINICAL NOTE The combination of a rightward axis and positive V1–3 suggests a left lateral accessory pathway • Sinus rhythm, 84 b.p.m., vertical axis +90° • Features of Wolff–Parkinson–White syndrome (Fig 98.1): – short PR interval (80 ms) – wide QRS – delta wave • Secondary ST–T changes (Fig 98.2) FEATURES OF THIS ECG The commonest site for an accessory pathway is the left lateral region Wolff–Parkinson–White syndrome (2) Fig 98.2 Fig 98.1 short PR P delta Lead V2 P delta Lead II II V2 T wave inversion SECTION 10 CASE 98 215 aVL aVF II III V1 aVR I Referred by: A 50-year-old man with bouts of tachycardia CASE 99 V3 V2 V1 Unconfirmed V6 V5 V4 216 In some people with this syndrome there is evidence of an AV perinodal accessory pathway, in others the abnormality appears to be enhanced AV nodal conduction CLINICAL NOTE Sinus rhythm, 75 b.p.m., normal QRS axis (+70°) Features of left ventricular hypertrophy, LVH (Fig 99.1) S (V2) + R (V5) > 35 mm ST depression and T wave inversion in leads with dominant R waves (LV strain pattern) • Features of Lown–Ganong–Levine syndrome (Fig 99.2): – short PR interval, 120 ms – normal QRS morphology – normal P wave axis (negative in aVR, positive in the inferolateral leads) • • • • FEATURES OF THIS ECG • Short PR interval (< 140 ms) • Normal P wave axis (unlike an ectopic atrial rhythm originating close to the AV node) • Normal QRS complex (no delta wave) Lown–Ganong–Levine syndrome Fig 99.2 aVF Fig 99.1 V2 18 mm 36 mm Short PR interval PR interval = 120 ms Features of LVH V5 18 mm SECTION 10 CASE 99 217 aVL aVF II III II aVR I V3 V2 V1 An 18-year-old woman who collapsed whilst jogging CASE 100 V6 V5 V4 218 In the above case: QTc = 0.68/√1.08 = 0.65 s (650 ms) QTc = QT (sec)/√R–R interval (sec) Romano–Ward syndrome (LQTS without deafness, autosomal dominant inheritance) Jervell–Lange–Nielsen syndrome (LQTS with congenital deafness, autosomal recessive inheritance) The chromosomal abnormalities differ between affected families but there are two major recognised phenotypes: The prolonged repolarisation seen in congenital LQTS is believed to be caused by abnormal function of a myocardial ion channel Increased sympathetic tone in these patients (often exercise induced) is known to trigger arrhythmias, particularly torsade de pointes ventricular tachycardia CLINICAL NOTE • Sinus bradycardia, 55 b.p.m., normal QRS axis • Two ventricular premature beats, VPBs (Fig 100.1) • Features of LQTS: – long QT interval, 680 ms uncorrected (Fig 100.2) – prominent U wave (Fig 100.3) FEATURES OF THIS ECG • Corrected QT interval > 440 ms • Abnormally prominent U waves (amplitude > 10% of T wave) • ‘Torsade de pointes’ ventricular tachycardia Congenital long QT syndrome (LQTS) Fig 100.3 Fig 100.2 V6 Fig 100.1 Lead V2 U wave prominent U wave Lead V6 Long QT interval QT interval = 680 ms Rhythm strip VPB premature, wide complex beat with no P wave full compensatory pause, i.e twice normal R–R interval To make sure that the myocardium has completely repolarised before the next depolarisation begins, the duration of the QT interval naturally decreases as the heart rate rises Therefore, to assess the normality of a given QT interval it is necessary to correct for the heart rate SECTION 10 CASE 100 219 II aVR aVL aVF I II III Referred by: A 45-year-old obese woman with chest pain CASE 101 V3 V2 V1 V6 V5 V4 Unconfirmed 220 To record a useful ECG in dextrocardia swap the left and right arm leads and place the chest leads in the same positions but swapped from left to right The chest pain was musculoskeletal in origin Her chest x-ray (Fig 101.3) shows dextrocardia and situs inversus Note air in the gastric fundus under the right diaphragm CLINICAL NOTE • Sinus rhythm, 96 b.p.m., right axis deviation • Features of dextrocardia: – inverted P wave in lead I (Fig 101.1) – abnormal chest leads (Fig 101.2): (i) no R wave progression (ii) QRS complexes becoming smaller from V1 to V6 FEATURES OF THIS ECG • Inverted P waves in lead I • Right axis deviation (usually) • The QRS complexes get progressively smaller from V1 to V6 Dextrocardia Inverted P waves in lead I Fig 101.3 Chest x-ray Fig 101.2 Unusually small R waves in the lateral chest leads V5 Fig 101.1 I inverted P wave SECTION 10 CASE 101 221 V4 V5 V6 V1 V2 V3 aVR aVL aVF II III I A 42-year-old man with a history of heart transplant for ischaemic cardiomyopathy CASE 102 222 The extreme axis deviation in this recipient is due to previous extensive infarction of the left ventricle The auxiliary heart is placed in the right iliac fossa and pumps in parallel with the native heart With the more commonly performed orthotopic heart transplant the native heart is removed and the donor organ put in its place CLINICAL NOTE • Native heart: – sinus tachycardia, 110 b.p.m., extreme axis deviation (−160°) – features of an old extensive anterolateral myocardial infarction with deep Q waves in lead I and V3–6 (Fig 102.1) • Donor heart: – sinus rhythm, 125 b.p.m., normal axis – features of dextrocardia: (i) negative P in lead I (Fig 102.2) (ii) small QRS complexes decreasing in size from V1 to V6 (Fig 102.3) FEATURES OF THIS ECG • Two independent ECGs on the same recording • One ECG with features of dextrocardia donor QRS complexes * V4 Fig 102.3 * ˆ * V5 V6 Donor chest lead complexes V3 V2 V1 ˆ native QRS complexes with positive preceding P waves ˆ ˆ Lead I * donor QRS complexes with negative preceding P waves * Lead V6 Fig 102.2 I Fig 102.1 native QRS complexes with deep waves V6 Auxiliary (heterotopic or ‘piggyback’) heart transplant SECTION 10 CASE 102 223 This page intentionally left blank 225 INDEX Subject index Main references are shown in bold A aberrant conduction 91 supraventricular tachycardia (SVT) 45 ablation, radiofrequency 29, 37, 39 accelerated idioventricular rhythm 55 accelerated junctional rhythm (AJR) 33 accessory pathway 41, 213, 215 see also Wolff–Parkinson–White syndrome adenosine 39, 45 alcohol 19, 21 alcoholic cirrhosis 169 amiodarone 11, 67 amyloidosis, cardiac 201 angina 10, 127, 129 angioplasty 135, 145 anxiety 3, 9, 129 aortic stenosis 79, 101 arrhythmogenic right ventricular dysplasia (ARVD) 203 arrowhead inversion 127 athletes 7, 11, 35, 197 atrial bigeminy 13 atrial fibrillation 21 left bundle branch block 25 paroxysmal 23 with rapid ventricular response 23 third degree heart block 107 Wolff–Parkinson–White syndrome 43 atrial flutter 27, 31, 91 2:1 AV block 29 atrial hypertrophy biatrial 155 left 9, 11, 33, 87, 153 right 151 atrial premature beat (APB) 11, 13, 15 atrial rhythm, ectopic 17 atrial septal defects 75 atrial trigeminy 15 atrioventricular block (AV block) 93–109 first degree 95 second degree 2:1 101 high grade 103 Mobitz type 1/Wenckebach AV 97 Mobitz type 99 third degree (complete) 87, 107, 109 atrial fibrillation 109 causes 105 narrow complex escape 107 wide complex escape 105 atrioventricular conduction 27 digoxin 177 ratios 27 atrioventricular dissociation 51, 57, 61, 63 atrioventricular nodal re-entry tachycardia 37 atrioventricular perinodal accessory pathway 217 atrioventricular reciprocating tachycardia antidromic 39, 41 orthodromic 39 atrioventricular sequential pacing 115 atropine AV sequential pacing 115 axis deviation auxiliary heart transplant 223 left 9, 25, 33, 79 causes 83 right 65, 157, 181, 191, 221 causes 85 B baseline wander 3, 29, 59 beta blocker 11, 35, 59 biatrial hypertrophy 155 bifascicular block 87, 103 bigeminy atrial 13 ventricular 53 biventricular hypertrophy 163 breasts 209 bulimia 173 bundle branch block 73–91 left see left bundle branch block right see right bundle branch block bundle of Kent (accessory pathway) 41, 213 localization 215 C calcium channel blockers 11, 35 calcium gluconate 171 capture beat 57, 59 cardiac amyloidosis 201 cardiac sinus massage cardiogenic shock 143 cardioversion 63 chest leads, misplaced 191, 193 chronic obstructive airways disease 151 cirrhosis, alcoholic 169 compensatory pause 51 complete heart block (CHB) see atrioventricular block, third degree concordance 57, 61 congenital heart disease 75 Cornell voltage criteria 159 D delta wave 39, 41, 43 dextrocardia 221 heart transplant 223 technical 191 diarrhoea 173, 175 digitalis 179 digoxin 11, 21, 109 effects 179 diuretic, potassium sparing dosulepin (dothiepin) 179 Down syndrome 156 Dressler’s syndrome 207 169 E Ebstein’s anomaly 151 ectopic atrial rhythm 17 ectopic beats atrial 11, 13, 15 junctional 143 ventricular see ventricular premature beats Eisenmenger syndrome 157 electrical alternans 209, 211 electrical axis deviation see axis deviation electrical interference 3, 185 emphysema 19 epsilon wave 203 exercise 5, 7, exercise tolerance test 103, 124 F Fallot’s tetralogy 75 fascicular block see left anterior hemiblock (LAHB); left posterior hemiblock (LPHB) fibrillary waves 21, 23 fibrotic degeneration 75, 79 first degree heart block 95 flecainide 23 flutter atrial 27, 29, 31, 91 ventricular 69 flutter line 27, 29 Framingham voltage criteria fusion beat 57, 59 G glaucoma 159 11 H haemodialysis 171 heart block see atrioventricular block heart transplant auxiliary (heterotopic/piggyback) 223 orthotopic 223 heparin 127 ‘high take off’ 131 His–Purkinje system 5, 99 hypercalcaemia 177 hyperkalaemia causes 169 extreme ECG features 171 subtle ECG changes 169 hyperparathyroidism 177 hypertension 10, 17, 21 hypertrophic obstructive cardiomyopathy (HOCM) 159 hypocalcaemia 175 hypokalaemia 173 hypothermia 167, 177 I idioventricular rhythm, accelerated 55 implantable cardioverter defibrillator (ICD) 121 infarction see myocardial infarction inspiration 7, 11 intraventricular conduction delay, non-specific 21, 31, 35, 53 irregular sinus rhythm ischaemic heart disease see myocardial ischaemia J Jervell–Lange–Nielsen syndrome 219 junctional bradycardia 35 junctional escape beats 35 junctional premature beat (JPB) 143 junctional rhythm, accelerated 33 juvenile pattern 197 J wave 167, 197 K ketoconazole 67 Kussmaul’s sign 208 L LAD artery, occluded 205 left anterior hemiblock (LAHB) 9, 33, 83, 167, 205 amyloidosis 201 atrial fibrillation 25 causes 79 right bundle branch block 87 left atrial abnormality 9, 11, 33, 87, 153 left bundle branch block (LBBB) 25, 79 acute anterior myocardial infarction 147 amyloidosis 201 atrial fibrillation 25 incomplete 81, 85 left posterior hemiblock (LPHB) 85, 199 causes 79 226 left ventricular aneurysm 205 left ventricular dysfunction 51, 53, 65 left ventricular hypertrophy (LVH) 11, 15, 99, 163, 197, 217 causes 161 chest lead criteria 161 limb lead criteria 159 voltage criteria 15, 159 left ventricular strain pattern 15, 157 long QT syndrome (LQTS) 121, 219 Lown–Ganong–Levine syndrome 217 LV strain pattern 159 M mitral regurgitation 81 mitral stenosis 153 mitral valve disease 80 Mobitz type AV block 97 Mobitz type AV block 99 multifocal atrial tachycardia 19 myocardial infarction acute anterior, with left bundle branch block 147 acute anterolateral 133 acute anteroseptal 135 acute extensive anterior 131 acute ‘high’ lateral 137 acute inferior 65, 139, 143 acute inferior with Wenkebach AV block 97 acute inferolateral 193 acute posterior 145 inferior 63 inferolateral (inferoapical) 55, 139, 145 non-Q wave 35 old anterior 51, 103 ventricular tachycardia 63 very early acute inferior 141 myocardial ischaemia 35, 123–147 non-specific changes 129 ST depression 125 T wave inversion 127 N non-respiratory sinus arrhythmia O obesity 209 P pacemaker 111–121 dual chamber 115, 119 failure to capture 119 failure to sense 117 insertion indications 47, 99, 115 nomenclature 113 ventricular 109, 113 pacing spike 113, 115 Parkinson’s disease 187, 189 paroxysmal SVT 37, 39, 45 pericardial effusion 209 causes 211 with electrical alternans 211 pericardial tamponade 209 pericarditis, acute 9, 207 phasic aberrant ventricular conduction 91 physiological pacing 119 P-mitrale 153 polymorphic ventricular tachycardia 65 with cardioversion and pacing 121 poor quality ECG recording 3, 183–193 potassium sparing diuretic 169 P–P interval, sinus arrhythmia P-pulmonale 151 pregnancy PR interval biatrial hypertrophy 155 digoxin 179 first degree heart block 95 Lown–Ganong–Levine syndrome 217 second degree heart block 97, 99, 101 PR segment depression, pericarditis 207 pulmonary embolus (PE), acute 199 pulmonary hypertension 151 P wave 3:1 AV block 103 absence 21, 23, 25, 37, 109 atrial bigeminy 13 atrial ectopic rhythm 17 atrial trigeminy 15 AV nodal re-entry tachycardia 37 AV reciprocating tachycardia 39 biphasic 155 dual chamber pacing 115 idioventricular rhythm, accelerated 55 inverted 35, 41, 191, 221 multifocal atrial tachycardia 19 negative 85 normal sinus rhythm notched 9, 153, 155 right atrial abnormality 151 right ventricular hypertrophy 157 sinus bradycardia 11 tall 151 ventricular bigeminy 53 ventricular premature beats 51 p’ wave 17 Q QRS complex atrial premature beat 13 auxiliary heart transplant 223 dextrocardia 221 left bundle branch block 79 incomplete 81 notching 53 right bundle branch block 75 right bundle branch block, incomplete small 209 QTc 219 QT interval congenital long QT syndrome 219 drug induced 67 hypercalcaemia 177 hypocalcaemia 175 long 65 short corrected 177 torsade de pointes 67 QU interval 173 Q wave 147 absence 83 athletic heart 197 multifocal atrial tachycardia 19 sinus bradycardia 11 ventricular premature beats 51 77 R radiofrequency ablation 29, 37, 39 re-entry circuit 41 displacement 29 respiratory sinus arrhythmia rheumatic triple valve disease 155 right atrial abnormality 151 right bundle branch block (RBBB) 33, 43, 45, 75, 189, 203 causes 75 incomplete 11, 77 left anterior hemiblock 87 long PR interval 89 right ventricular hypertrophy (RVH) 153, 157, 163 right ventricular infarction, acute 143 Romano–Ward syndrome 219 Romhilt & Estes points score system 159 R on T phenomenon 67 R–R intervals short 43, 91 ventricular premature beats 51 R–S interval 45 RsR’ complex 81 rSr’ pattern 11, 75, 77, 191 R wave 25, 83, 87, 89 LVH 159 myocardial infarction 145 notching 81 right ventricular hypertrophy 157 secondary (R’) 75 R wave progression, poor 133 misplaced chest leads 193 S S1 Q3 T3 pattern 85, 199 sawtooth wave 27, 29, 31 second degree heart block see atrioventricular block, second degree shivering artifact 167 sick sinus syndrome 9, 47, 115 sine wave 69 sinus arrest 35, 47 sinus arrhythmia associations sinus bradycardia 11, 47 sinus rhythm irregular normal with normal U wave sinus tachycardia 9, 63, 199 situs inversus 221 skeletal muscle interference 3, 187, 189 Sokolow & Lyon voltage criteria 159 sotalol 203 spironolactone 169 ST depression atrial fibrillation 21 horizontal 125 left ventricular hypertrophy 15 myocardial infarction 131, 133, 135, 137, 139, 141, 145 pericarditis 207 sloping 125 tachycardia 37, 39 ST elevation 79 causes 131 myocardial infarction 133, 135, 137, 139, 141, 143, 147 pericardial effusion 209 saddle shaped 207 ST-J point 179 ST segment changes 147 digoxin 179 hypocalcaemia 175 ST-T changes atrial fibrillation 23 primary 147 secondary 147 left bundle branch block (LBBB) 79 Wolff–Parkinson–White syndrome 213, 215 sinus bradycardia 11 227 subendocardial myocardial infarction supraventricular rhythms 1–47 supraventricular tachycardia (SVT) aberrant conduction 45 paroxysmal 37, 39, 45 S wave notching 77 right bundle branch block (RBBB), incomplete 77 right ventricular hypertrophy 157 slurring 75 35 T technical issues 3, 183–193 terfenadine 67 third degree heart block see atrioventricular block, third degree thrombolysis 141 thyrotoxicosis 5, 9, 21, 27 torsade de points ventricular tachycardia 65, 67, 71, 219 tricuspid valve stenosis 151 tricyclic antidepressant overdose 181 trifascicular block 33, 89 troponin-T 147 Ta wave 151 T wave apex 37 T wave changes 129, 147 athletic heart 197 hypercalcaemia 177 hyperkalaemia 169, 171 myocardial infarction 145 T wave inversion 15, 37, 75, 83, 85, 127, 199, 203 pericarditis 207 U uraemia 11 U wave congenital long QT syndrome 219 inverted 5, 159 left ventricular hypertrophy 15 prominent 5, 109 V ventricular bigeminy 53 ventricular fibrillation (VF) 69, 71 ventricular flutter 69 ventricular hypertrophy biventricular 163 left see left ventricular hypertrophy right 153, 157, 163 ventricular premature beats (VPB) 33, 51, 53, 55, 61 anterior myocardial infarction 131 congenital long QT syndrome 219 right ventricular infarction 143 in torsade de pointes 67 ventricular bigeminy 53 ventricular rhythms 49–71 electrical origins 55 ventricular tachycardia (VT) atrioventricular dissociation 57 capture and fusion beats 59 faulty pacemaker 117 morphology of VPB 61 myocardial infarction 63 polymorphic 65, 121 torsade de pointes 65, 67, 71, 219 ventriculo-phasic sinus arrhythmia vitamin D deficiency 175 voltage criteria, left ventricular hypertrophy 15, 159 VVIR pacemaker 113 W wandering atrial pacemaker 19 Wenckebach AV block 97 wide complex tachycardia 33 differential diagnosis 45 Wolff–Parkinson–White syndrome 215 accessory pathway localization atrial fibrillation 43 differential diagnosis 213 tachycardia 39, 41 ventricular pre-excitation 213 215 This page intentionally left blank .. .ECGs by Example For Elsevier Senior Commissioning Editor : Laurence Hunter Development Editor : Carole... Project Manager : Cheryl Brant Designer : Charles Gray Illustration Manager: Gillian Richards ECGs by Example Dean Jenkins Stephen Gerred MB BCh DipMedEd FRCP MBChB FRACP Honorary Consultant Physician... ECG Made Easy”, but still get fazed by the real thing when it confronts you in the Emergency Department or on the ward, then this book is for you All the examples are actual ECG recordings as