Arrhythmia Recognition: The Art of Interpretation

Cover
Arrhythmia Recognition The Art of Interpretation
Copyright
Brief Contents
Contents
Resources
Dedications and Biographies
Acknowledgments
Foreword
Section 1: Introduction to Arrhythmia Recognition
	Chapter 1: Anatomy and Basic Physiology
		Beginner’s Perspective
		Gross Anatomy
			Anterior View
			The Heart in Cross Section
		The Heart as a Pump
			Pump Function Simplified
		Cardiac Output
			Passive Pumping
			Active Pumping
		The Electrical Conduction System
			Pacemaker Function
			Pacemaker Settings
			The Sinoatrial (SA) Node
			The Internodal Pathways
			The Atrioventricular (AV) Node
			The Bundle of His
			The Left Bundle Branch (LBB)
			The Right Bundle Branch (RBB)
			The Left Anterior Fascicle (LAF)
			The Left Posterior Fascicle (LPF)
			The Purkinje System
		Chapter Review
	Chapter 2: Electrophysiology
		Beginner’s Perspective
		Introduction
		Mechanics of Contraction
		Ion Movement and Polarity
		Membrane Channels and Action Potential Phases
		Introduction to the Nervous System and Cardiac Function
			Central Nervous System (CNS)
			Peripheral Nervous System (PNS)
		Chapter Review
	Chapter 3: Paper, Tools, and Calculating Rates
		Boxes and Sizes
		Calibration
		Temporal Relationship of Multiple-Lead Strips
			Why Is Temporal Spacing Important?
		ECG Tools
		Calipers: The Clinician’s Best Friend
			How to Use Your Calipers
			Comparing Widths
		ECG Rulers
		Straightedge
		The Rate
		Establishing the Rate
			Normal and Fast Rates
			Bradycardic Rates
		Let’s practice calculating some rates . . .
		Calculate the rates . . .
		Chapter Review
	Chapter 4: Vectors and the Basic Beat
		Beginner’s Perspective
		Introduction
		Adding and Subtracting Vectors
		The Electrical Axis of the Heart
		Electrodes and Waves
		Leads Are Like Pictures of the Heart
			Lead Placement (Where to Put the “Cameras”)
			How the Machine Manipulates the Leads
		The Two Lead Systems
			The Hexaxial System
			The Precordial System
		The Basic Beat
		Introduction to Basic Components
			Wave Nomenclature
		Individual Components of the ECG Complex
			The P Wave
			The Tp Wave
			The PR Segment
			The PR Interval
			The QRS Complex
			The ST Segment
			The T Wave
			The QT interval
			The U Wave
			Additional Intervals
		Chapter Review
	Chapter 5: Introduction to 12-Lead ECGs
		Introduction
		Basic Information
			Localizing an Area: Inferior Wall
			Localizing Other Areas
		The Electrical Axis
		How to Calculate the Electrical Axis
		Bundle Branch Blocks
			What Happens If One Side Is Blocked?
			Right Bundle Branch Block (RBBB)
			Left Bundle Branch Block (LBBB)
		Chapter Review
	Chapter 6: Electrocardiography and Arrhythmia Recognition
		Beginner’s Perspective
		Introduction
		Artifact
		Premature Complexes
		Escape Complexes and Rhythms
		Ectopic Foci and Their Morphologies
			Ectopic Foci in the Ventricles
		Aberrancy
		Fusion
			The Isolated Electrocardiographic Type of Fusion
			Actual Fusion
		Chapter Review
	Chapter 7: How to Interpret a Rhythm Strip
		Introduction
		10 Questions
		General Questions
			1. Is the rhythm fast or slow?
			2. Is the rhythm regular or irregular? If irregular, is it regularly irregular or irregularly irregular?
		Questions Related to P Waves
			3. Do you see any P waves?
			4. Are all the P waves the same?
			5. Does each QRS complex have a P wave?
			6. Is the PR interval constant?
		Questions Related to the QRS Complexes
			7. Are the P waves and QRS complexes associated with one another?
			8. Are the QRS complexes narrow or wide?
			9. Are the QRS complexes grouped or not grouped?
			10. Are there any dropped beats?
		A Final Thought Before We Move On
		Individual Rhythms
			Supraventricular Rhythms
		Ventricular Rhythms
			Heart Blocks
		Beginner’s Perspective
		Chapter Review
Section 2: Sinus Rhythms
	Chapter 8: Normal Sinus Rhythm
		Beginner’s Perspective
		Introduction to Sinus Rhythms
		Normal Sinus Rhythm
		The Formation of the ECG
		Regularity
			Regularly Irregular Rhythms
			Irregularly Irregular Rhythms
		ECG Strips
		Chapter Review
	Chapter 9: Sinus Bradycardia
		Introduction
		When Is Sinus Bradycardia Considered a Cardiac Emergency?
		ECG Strips
		Chapter Review
	Chapter 10: Sinus Tachycardia
		Beginner’s Perspective
		Introduction
		A Quick Clinical Word
		Clinical Characteristics
			Rate
		ECG Strips
		Chapter Review
	Chapter 11: Sinus Arrhythmia
		Introduction
		Respiratory Sinus Arrhythmia
		Nonrespiratory or Nonphasic Sinus Arrhythmia
		Some Additional Clinical Points
		ECG Strips
		Chapter Review
	Chapter 12: Sinus Blocks, Pauses, and Arrests
		Beginner’s Perspective
		Introduction
		Sinus Block
		Sinus Pause and Sinus Arrest
		ECG Strips
		Chapter Review
		Section 2 Self-Test
Section 3: Atrial Rhythms
	Chapter 13: Premature Atrial Contraction
		Beginner’s Perspective
		Introduction
		The P-Wave Axis
		PACs and the PR Interval
		The Pause
		The PAC and Aberrancy
		The Hidden PAC
			P Falling on a T
		Blocked PACs
		ECG Strips
		Chapter Review
	Chapter 14: Ectopic Atrial Rhythm
		Introduction
		Diagnostic Challenges
		Hint #1: Always Try to Compare Your New Strip to an Old ECG or Rhythm Strip
		Hint #2: Always Evaluate the P-Wave Morphology and the PR Interval
		ECG Strips
		Chapter Review
	Chapter 15: Focal Atrial Tachycardia
		Beginner’s Perspective
		Introduction
		ECG Strips
		Chapter Review
	chapter 16: Focal Atrial Tachycardia
with Block
		Introduction
		Diagnostic Criteria
		P Waves in Focal AT with Block
		The Problem with Lead II
		ECG Strips
		Chapter Review
	chapter 17: Wandering Atrial
Pacemaker
		BEGINNER’S PERSPECTIVE
		Introduction
		Wandering Atrial Pacemaker: The Classical Definition
		Wandering Atrial Pacemaker: A Clinical Variation
		ECG Strips
		Chapter Review
	Chapter 18: Multifocal Atrial Tachycardia
		Introduction
		Clinical Scenario
		ECG Strips
		Chapter Review
	Chapter 19: Atrial Flutter
		General Overview
		The Making of the Saw-Tooth Pattern
		AV Nodal Conduction Rates
		Atrial and Ventricular Rates
		Recognizing Atrial Flutter
		Atrial Flutter and Wide-Complex Tachycardias
		ECG Strips
		Chapter Review
	Chapter 20: Atrial Fibrillation
		General Information
		How f Waves Are Created
		Ventricular Response
		Clinical Implications
		Regular Ventricular Response in Atrial Fibrillation
		The Morphology of the Complexes in Atrial Fibrillation
			The QRS Complex in Atrial Fibrillation
		ST Segments and T Waves
		ECG Strips
		Chapter Review
		Section 3 Self-Test
Section 4: Junctional Rhythms
	Chapter 21: Introduction to Junctional Rhythms
		A Closer Look at the AV Node
		The Junction as a Pacemaker
		Junctional Rhythms: An Overview
		Chapter Review
	Chapter 22: Premature Junctional Contraction
		Introduction
		ECG Strips
		Chapter Review
	Chapter 23: Junctional Rhythm
		Beginner’s Perspective
		Introduction
		Junctional Escape Complexes and Rhythms
		ECG Strips
		Chapter Review
	Chapter 24: Rapid Junctional Rhythms
		Introduction
		Pseudo-S and Pseudo-R’ Waves
		ECG Strips
		Chapter Review
	Chapter 25: AV Nodal Reentry Tachycardia
		General Overview
		Step 1: General Concepts in AV Nodal Reentry
		Step 2: Reentry and AVNRT
		Step 3: Identifying the Arrhythmia
		ECG Strips
		Chapter Review
	Chapter 26: AV Reentry Tachycardia
		Introduction
		Normal Conduction Through an Accessory Pathway
		AVRT Reentry Circuits
		Orthodromic AVRT
			The P Wave and AVRT
			Other Important Clinical Facts
		Antidromic AVRT
		ECG Strips
		Chapter Review
	Chapter 27: Narrow-Complex Supraventricular Tachycardia
		Beginner’s Perspective
		Before We Move On
		What Is an SVT?
		Review of Narrow-Complex SVTs
			1. Physiologic Sinus Tachycardia
			2. Inappropriate Sinus Tachycardia
			3. Focal Atrial Tachycardia
			4. Multifocal Atrial Tachycardia
			5. AV Nodal Reentry Tachycardia
			6. Orthodromic AV Reentry Tachycardia
			7. Junctional Tachycardia
			8. Atrial Flutter
			9. Atrial Fibrillation
		How to Approach a Narrow-Complex SVT
			Clinical Presentation
			History and Physical Examination
		Evaluating the Strip or ECG
			General Discussion
			Narrow Complex vs. Wide Complex
			Rate
			Conduction Ratio
			Regularity
			P-Wave Morphology and Orientation
			The P-QRS Relationship
			A Closer Look at RP Interval
			AV Node–Dependent vs. –Independent Classification
			Other Things to Watch Out For
			Pharmaceutical Adjuncts
			Electrophysiologic Intervention
			Differential Diagnosis
		Hemodynamic Consequences of a Tachycardia
			Heart Rate and Hemodynamics
			A Few Extra Seconds
		Focused Treatment Requires Focused Identification
		Chapter Review
	Chapter 28: Atrioventricular Blocks
		General Overview
		First-Degree AV Block
		ECG Strips
		Second-Degree AV Block
			Mobitz I Second-Degree AV Block or Wenckebach
			Mobitz I Second-Degree AV Block: A Final Word
			Mobitz II Second-Degree AV Block
			Untypable or 2:1 Second-Degree AV Block
			High-Grade or Advanced AV Block
		Complete or Third-Degree AV Block
		Chapter Review
		Section 4 Self-Test
Section 5: Ventricular Rhythms
	Chapter 29: Introduction to Ventricular Rhythms
		Introduction
		Morphology
		The Ventricle as a Pacemaker
		The P Wave in Ventricular Rhythms
			P-Wave Morphology in Ventricular Rhythms
			The P:QRS Relationship in Ventricular Rhythms
		Ventricular Rhythms: General Overview
		Chapter Review
	Chapter 30: Premature Ventricular Contraction
		General Overview
		Coupling Interval
		Compensatory vs. Noncompensatory Pauses
		Unifocal vs. Multifocal PVCs
		Bigeminy, Trigeminy, and More
		Couplets, Triplets, and Salvos
		The P Wave and PVCs
		Fusion Complexes
		ECG Strips
		Chapter Review
	Chapter 31: Ventricular Escape and Idioventricular Rhythms
		General Overview
		Ventricular Escape Complexes
		Idioventricular Rhythm
		Accelerated Idioventricular Rhythm
		Capture Beats
		ECG Strips
		Chapter Review
	Chapter 32: Ventricular Tachycardia
		General Overview
		Reentry and Other Possible Mechanisms
			1. The presence of an electrical circuit with at least two pathways
			2. The two pathways must have different properties
			3. An area of slowing in one of the circuits—just enough to allow the rest of the circuit to get over its refractory period
		General Characteristics of Ventricular Tachycardia
			Morphology of the Complexes and Arrhythmia Recognition
			Regularity
			AV Dissociation
			Similar Morphology to PVCs
		Nonsustained Monomorphic Ventricular Tachycardia
		Sustained Monomorphic Ventricular Tachycardia
		Ventricular Flutter
		ECG Strips
		Chapter Review
	Chapter 33: Polymorphic Ventricular Tachycardia and Torsade de Pointes
		General Overview
		Polymorphic Ventricular Tachycardia
		Torsade de Pointes
			Onset of Torsade de Pointes
			The Turning of the Points
			Causes of Torsade de Pointes
		ECG Strips
		Chapter Review
	Chapter 34: Wide-Complex Tachycardia: The Basics
		Introduction
		A Quick Recap and the WCT Umbrella
		Wide-Complex Tachycardias: What Makes Them Wide
		The Five Groups Comprising the Wide-Complex Tachycardias
			1. Ventricular Tachycardia
			2. Supraventricular Tachycardias with Rate-Related Aberrancy
			3. SVT-A with Preexisting BBB or IVCD
			4. SVT-A Due to Metabolic, Physiologic, Pharmacologic, or Paced Causes (MP3s)
			5. SVT-A Due to Conduction Over an Accessory Pathway
		A Final Thought
		Chapter Review
	Chapter 35: Wide-Complex Tachycardia: The Approach
		The Emerging WCT Paradigm Shift
		The Three Clinical Stages
		The Emergent Evaluation of WCTs Made Insanely Simple!
			Our Rationale: Hemodynamic Status
			Our Rationale: VTach, VTach, VTach . . .
		How to Manage the Emergent Period
		Nonurgent Evaluation of the WCTs
		Final Thoughts
		Chapter Review
	Chapter 36: Wide-Complex Tachycardia: Criteria
		Introduction
		Wide-Complex Tachycardias: Nonurgent Stage
		Section I: The Criteria
			History and Physical Examination
			QRS Interval Width
			Regularity
			QRS Morphology
			AV Dissociation
			Concordance of the QRS Complexes in the Precordial Leads
			Abnormal Axis Deviation
			Hemodynamic Status
			Other Adjuncts to the Diagnosis of WCT
		Section II: The Algorithms
			The Brugada Algorithm
			The Vereckei aVR Algorithm
		Final Thoughts
		Chapter Review
	Chapter 37: Wide-Complex Tachycardia: Putting It All Together
		Introduction
		Putting It All Together
		The Worksheet
		Case 1
			Clinical Scenario
			Final Assessment
		Case 2
			Clinical Scenario
			Final Assessment
		Case 3
			Clinical Scenario
			Final Assessment
		Case 4
			Clinical Scenario
			Final Assessment
		Case 5
			Clinical Scenario
			Final Assessment
	Chapter 38: Ventricular Fibrillation and Asystole
		Ventricular Fibrillation
		Asystole
			Agonal  Rhythm
		ECG Strips
		Chapter Review
		Section 5 Self-Test
Section 6: Additional Rhythms and Information
	Chapter 39: Artificially Paced Rhythms
		General Overview
		Pacemaker Code
		The Pacemaker Spike
		QRS Morphology in a Paced Rhythm
		Popular Pacemaker Modes
			Atrial Demand Pacemaker
			Ventricular Demand Pacemaker
			AV Sequential
			Automatic Pacemaker
		ECG Strips
		Chapter Review
	Chapter 40: Putting It All Together
		Introduction
		“Patient’s”
			The History
			Physical Examination
		“Impression”
		Top 10 “Questions”
			1. Is the Rhythm Fast or Slow?
			2. Is the Rhythm Regular or Irregular?
			3. Do You See Any P Waves?
			4. Are the P Waves the Same?
			5. Are the P Waves Upright in Lead II?
			6. Are the PR Intervals Normal and Consistent?
			7. What Is the P:QRS Ratio?
			8. Are the QRS Complexes Narrow or Wide?
			9. Are the Complexes Grouped or Not Grouped?
			10. Are There Any Dropped P Waves?
			Have I Mined for Gold?
			How Can I Put It All Together?
		“Points”
		Let’s Go Through an Example
			Overall Impression of the Rhythm
			Question 1: Is the Rhythm Fast or Slow?
			Question 2: Is the Rhythm Regular or Irregular?
			Question 3: Do You See Any P Waves?
			Question 4: Are All of the P Waves the Same?
			Question 5: Are the P Waves Upright in Lead II?
			Question 6: Are the PR Intervals Normal and Consistent?
			Question 7: What Is the P:QRS Ratio?
			Question 8: Are the QRS Complexes Narrow or Wide?
			Question 9: Are the Complexes Grouped or Not Grouped?
			Question 10: Are There Any Dropped Beats?
			Have I Mined for Gold?
		Chapter Review
Section 7: Final Tests
	Final Test 1
	Final Test 1 Answers
	Final Test 2
	Final Test 2 Answers
Chapter Review Answers
Abbreviations
Glossary
ECG Index
Subject Index