Chou's Electrocardiography in Clinical Practice: Adult and Pediatric

Cover......Page 1
PREFACE......Page 4
CONTRIBUTING AUTHORS......Page 5
Dipoles......Page 6
Volume Conductor......Page 8
ECG Leads......Page 9
Intrinsic and Intrinsicoid Deflections......Page 10
Magnetocardiography......Page 11
Signal-Averaged ECG......Page 12
PR Interval......Page 13
Later Activation......Page 14
QRS Duration......Page 15
QRS Axis......Page 16
Q Wave......Page 17
R Wave......Page 19
S Wave......Page 21
T Wave......Page 22
QT Interval......Page 24
Differences between Ventricular Repolarization in Men and Women......Page 25
U Wave......Page 27
\"Early Repolarization\" Variant......Page 28
Athlete\'s Heart......Page 29
Obesity and Edema......Page 30
References......Page 31
Unicentric and Multicentric Pacemaker......Page 34
General Approach to Recognizing P Wave Abnormalities......Page 35
P Wave Abnormalities Originating in or near the Sinus Node......Page 36
Tall P Wave in Lead V1 or V2......Page 37
P Pulmonale......Page 38
Echocardiographic Correlations......Page 40
Left Atrial Abnormality......Page 41
Wide and Notched P Waves......Page 43
Atrial Enlargement in the Presence of Atrial Fibrillation......Page 45
Nonspecific Interatrial and Intraatrial Conduction Disturbances......Page 46
Atrial Repolarization......Page 47
References......Page 48
Left Ventricular Mass......Page 50
Proximity of the Heart to the Chest Wall......Page 51
Diagnostic Criteria for Patients Aged 40 Years or Older......Page 52
ST Segment and T Wave Changes......Page 53
Incomplete Left Bundle Branch Block......Page 55
Poor R Wave Progression in Precordial Leads......Page 56
Systolic and Diastolic Overload of the Left Ventricle......Page 57
Physiologic Factors Affecting the Reliability of Diagnostic Criteria......Page 58
Age......Page 59
Pathologic States Affecting the Diagnosis of LVH......Page 60
Assessment of the Severity of Valvular Lesions Causing LVH......Page 61
Right Ventricular Hypertrophy and Dilation......Page 62
Typical RVH Pattern......Page 63
Echocardiographic Correlations......Page 64
Tall R Wave, Small S Wave, Increased R/S Ratio in Lead V1 in Conditions Other than RVH......Page 65
Deep S Wave, Small R Wave, R/S Ratio <1 in Leads V5 and V6......Page 67
S1S2S3 Pattern as a Manifestation of RVH......Page 68
Incomplete RBBB......Page 69
Severity of Chronic Lung Disease......Page 70
Pulmonary Hypertension in Mitral Stenosis......Page 71
Clinical and Anatomic Correlations......Page 73
References......Page 75
Pathogenesis......Page 80
Clinical Significance and Prognosis......Page 81
QRS Axis in the Frontal Plane......Page 83
QRS Duration......Page 85
Incomplete LBBB......Page 86
Recognition of Myocardial Ischemia and Myocardial Infarction in the Presence of LBBB......Page 87
Primary T Wave Abnormalities......Page 89
QRS Changes......Page 90
Mechanism of Cycle Length-Dependent Bundle Branch Block......Page 94
Wenckebach Periodicity......Page 95
How Complete Is \"Complete\" Bundle Branch Block?......Page 96
References......Page 97
Complete Right Bundle Branch Block......Page 100
Anatomic Correlation......Page 102
RBBB in the General Population......Page 104
RBBB and Acute Myocardial Infarction......Page 105
RBBB Associated with Other Heart Disease......Page 106
Ventricular Hypertrophy in the Presence of RBBB......Page 107
Incomplete RBBB and rSr\' Pattern in Right Precordial Leads: Clinical Significance......Page 109
References......Page 111
Left Anterior Fascicular Block......Page 113
Superior (Left) Axis Deviation in the Frontal Plane......Page 116
Left Anterior Fascicular Block in Patients with Coronary Artery Disease and Hypertension......Page 117
LVH in the Presence of Left Anterior Fascicular Block......Page 118
Abnormal Right Axis Deviation......Page 119
Uncertain Role of Midseptal Fascicles......Page 120
Bilateral Bundle Branch Block......Page 121
RBBB and Left Anterior Fascicular Block......Page 122
RBBB and Left Anterior Fascicular Block: Relation to Complete AV Block......Page 123
Trifascicular Block......Page 124
Intraventricular Conduction Disturbances Associated with Myocardial Infarction and Periinfarction Block......Page 125
Nonspecific Intraventricular Conduction Disturbances......Page 126
References......Page 127
Systolic and Diastolic Currents of Injury......Page 129
Depression and Elevation of the ST Segment......Page 131
Localization of ST Segment Elevation and Reciprocal ST Segment Depression......Page 132
Anterior Wall MI and Occlusion of the LAD Coronary Artery......Page 133
Distal LAD Occlusion......Page 135
Left Main Coronary Artery Occlusion......Page 136
ST Segment Deviation in Lead aVR......Page 137
Inferior Wall MI and Occlusion of RCA or Left Circumflex Coronary Artery......Page 138
Right or Circumflex Coronary Occlusion?......Page 140
Lateral, Inferolateral, and Posterolateral MI......Page 142
Acute Injury Pattern in Right Precordial Leads......Page 143
Tombstoning Pattern......Page 144
Brugada and Other RSR\' Patterns with ST Elevation in the Right Precordial Leads......Page 145
ST Segment Changes as a Guide to Thrombolytic Therapy......Page 147
ST Segment Shift during Percutaneous Coronary Angioplasty......Page 148
Persistent ST Segment Elevation after MI......Page 149
Recognition and Significance of Reciprocal ST Changes with Acute MI......Page 151
Absence of the Expected Reciprocal ST Segment Deviation......Page 152
ST Segment Elevation: Normal Variant and Acute Pericarditis......Page 153
T Wave Changes (Hyperacute T Wave Pattern)......Page 155
U Wave......Page 156
Reversible QRS Changes......Page 158
Ventricular Arrhythmias during Acute Ischemia......Page 160
References......Page 161
Origin of the Abnormal Initial QRS Deflection......Page 167
MI with Abnormal Q Wave......Page 168
Q Wave vs. Non-Q Wave Infarction......Page 169
ECG Localization of MI......Page 170
Anterior MI Caused by Left Anterior Descending Coronary Artery Occlusion......Page 171
Posterior, Posterolateral Infarction, and Differential Diagnosis of Tall R Waves in Lead V1......Page 172
Right Ventricular Infarction......Page 173
Multiple Infarctions......Page 174
Optimal Leads......Page 176
Periinfarction Block......Page 177
Angiographic Correlations......Page 179
Evolution of ECG Patterns for Acute Q Wave MI......Page 185
Increased R Amplitude......Page 187
Thrombolytic Treatment and Primary Angioplasty in Acute MI......Page 188
Sensitivity and Specificity of the ECG......Page 189
Estimation of MI Size by the QRS Scoring System......Page 191
Prognostic Value of ECG for MI......Page 192
Long-Term Prognosis......Page 193
ECG Findings Predictive of Cardiac Rupture......Page 194
Altered Distribution of Myocardial Mass......Page 195
Altered Sequence of Depolarization and Abnormal Position of the Heart......Page 198
Pulmonary Embolism and Acute Cor Pulmonale......Page 200
Other Uncommon Pseudoinfarction Patterns......Page 201
References......Page 203
9 Non-Q Wave Myocardial Infarction, Non-ST Elevation Myocardial Infarction, Unstable Angina Pectoris, Myocardial Ischemia......Page 210
Non-Q Wave Myocardial Infarction (NQMI)......Page 211
ECG Diagnosis of NQMI......Page 212
Unstable Angina Pectoris (UAP)......Page 215
Categories of UAP......Page 216
Severity and Extent of ECG Abnormalities......Page 217
ST Segment Deviations......Page 218
ST Segment Elevation in the Absence of Myocardial Ischemia......Page 219
Increased Amplitude of Upright T Wave......Page 220
T Wave Abnormalities Attributed to Myocardial Damage......Page 221
Atrial Infarction......Page 222
References......Page 223
Introduction......Page 226
Safety of the Exercise Test......Page 227
Graded Exercise Test......Page 228
Blood Pressure Response to Exercise......Page 229
Recording Techniques......Page 230
Predictive Value of a Test Result......Page 231
Conventional Criteria......Page 232
Less Commonly Used or Controversial Criteria......Page 240
Positive Exercise Tests in the Absence of Obstructive CAD......Page 244
Exercise Testing in Patients with Abnormal Resting ECGs......Page 246
Asymptomatic and Unselected Subjects......Page 247
Atrial Arrhythmias......Page 250
Ventricular Arrhythmias......Page 251
References......Page 253
Electrical Alternans......Page 261
PR Segment Changes......Page 263
Cardiac Arrhythmias......Page 265
Incidence and Magnitude of ECG Abnormalities......Page 267
ECG Findings in Chronic Constrictive Pericarditis......Page 269
ECG Changes after Cardiac Surgery......Page 270
References......Page 275
Cardiomyopathies......Page 278
Dilated Cardiomyopathy......Page 279
Hypertrophic Cardiomyopathy......Page 281
Arrhythmogenic Right Ventricular Dysplasia......Page 284
Friedreich\'s Ataxia......Page 285
Myotonic Dystrophy......Page 286
Scleroderma Heart Disease......Page 287
Acute Rheumatic Fever and Rheumatic Carditis......Page 288
Myocardial Tumors......Page 289
Endocrine Disorders......Page 290
Hyperthyroidism......Page 291
Hypoparathyroidism......Page 293
Diseases of the Hypothalamus and Pituitary......Page 294
Turner Syndrome Phenotype and Sex Chromosome Abnormalities......Page 295
Diabetes Mellitus......Page 296
Amyloidosis......Page 297
Lipid Storage Disease......Page 298
Viral Myocarditis......Page 299
Heart Transplantation......Page 301
Trauma to the Heart......Page 303
Chronic Obstructive Pulmonary Disease......Page 304
Correlation with Severity of Lung Disease......Page 306
Arrhythmias and COPD......Page 310
ECG Findings......Page 311
ECG Differentiation of MI from Pulmonary Embolism and Chronic Cor Pulmonale......Page 312
Congenital Heart Disease in Adults......Page 313
Atrial Septal Defect......Page 314
Patent Ductus Arteriosus......Page 318
Pulmonary Stenosis......Page 319
Tetralogy of Fallot......Page 320
Ebstein\'s Anomaly......Page 321
Survivors of Switch Operation for Complete Transposition of Great Vessels......Page 323
Corrected Transposition of Great Vessels......Page 324
References......Page 325
13 Sinus Rhythms......Page 332
Sinus Arrhythmias......Page 333
Sinus Bradycardia......Page 334
Sinus Tachycardia......Page 335
Inappropriate Sinus Tachycardia......Page 336
Sinus Node Reentry and Reentrant Tachycardia......Page 337
Sinoatrial Block......Page 339
Sick Sinus Syndrome......Page 341
Tachycardia-Bradycardia Syndrome......Page 343
Sinus Node Recovery Time......Page 346
References......Page 347
Premature Atrial Impulses: Atrial Extrasystoles, Premature Atrial Depolarizations......Page 350
Postextrasystolic Pause......Page 352
Clinical Significance......Page 353
Automatic Ectopic Atrial Tachycardia......Page 354
ECG Findings......Page 356
Intraatrial Reentry Tachycardia......Page 357
Paroxysmal Atrial Tachycardia with’Block......Page 358
Clinical Significance......Page 359
Atrial Standstill......Page 360
Multifocal Atrial or Chaotic Tachycardia......Page 361
Atrial Dissociation......Page 362
References......Page 363
Clinical Correlation......Page 366
Relation of Atrial Flutter to Other Atrial Arrhythmias and Differential Diagnosis......Page 368
Mechanisms of Atrial Flutter......Page 371
Classification......Page 372
Atrial Fibrillation......Page 374
Ventricular Response......Page 376
Pharmacologic and Mechanical Slowing of Ventricular Response......Page 380
Morphology of Fibrillatory Waves......Page 381
Mechanism of Atrial Fibrillation......Page 382
Implications for Treatment......Page 383
Diagnosis of Premature Ventricular Complexes in the Presence of Atrial Fibrillation......Page 384
References......Page 385
Coronary Sinus Rhythm......Page 389
AV Junctional Escape Impulses......Page 390
AV Junctional Escape Rhythms......Page 392
ECG Findings......Page 393
Differential Diagnosis......Page 394
Accelerated AV Junctional Rhythm (Nonparoxysmal Junctional Tachycardia)......Page 395
AV Dissociation......Page 396
AV Nodal Reentrant Tachycardia......Page 397
Dual AV Nodal Pathways......Page 398
Common AV Nodal Tachycardia......Page 399
Uncommon AV Nodal Tachycardia......Page 400
Differential Diagnosis of AVNRT......Page 402
Reciprocal Impulses of Junctional Origin......Page 405
Reciprocal Impulses of Ventricular Origin......Page 406
References......Page 407
Premature Ventricular Complexes......Page 410
Fusion Complexes......Page 411
Concealed PVC......Page 412
Site of Origin......Page 413
Interpolated PVCs......Page 415
Couplets and Triplets......Page 417
Physiologic Aberration......Page 418
\"Pathologic\" Aberration......Page 419
Differentiation of PVCs from Premature Supraventricular Complexes with Aberrant Ventricular Conduction......Page 420
Heart Disease......Page 421
Ventricular Parasystole......Page 422
Regularity......Page 425
AV Dissociation......Page 426
Using the ECG to Localize the Site of Origin of VT......Page 428
Polymorphism (or Pleomorphism) of VT......Page 429
Ventricular Escape Complexes and Idioventricular Rhythm......Page 430
Accelerated Ventricular Rhythms......Page 433
Classification by Symptoms......Page 434
Classification by Response to Drugs......Page 435
Clinical Correlation......Page 436
Mechanisms of Ventricular Arrhythmias......Page 437
Reentry......Page 438
Abnormal Automaticity......Page 439
References......Page 440
Paroxysm......Page 445
Clinical Correlation......Page 446
Mechanism of TDP......Page 448
Ventricular Flutter and Fibrillation......Page 449
Onset of Tachycardias......Page 450
Vagal Stimulation and Adenosine Administration......Page 451
Morphology of the QRS Complex......Page 452
Criteria Based on Correlations with Intracardiac Studies......Page 454
References......Page 458
AV Conduction Defect with Normal PR Interval......Page 461
First-Degree AV Block......Page 462
ECG Findings......Page 464
2:1 AV Block......Page 466
High-Grade or Advanced AV Block......Page 467
ECG Findings......Page 469
AV Block with Preserved Retrograde VA Conduction......Page 471
Normal Subjects......Page 472
Coronary Artery Disease......Page 473
Degenerative Diseases of the Conducting System......Page 474
Valvular Heart Diseases......Page 475
Concealed Conduction......Page 476
Concealed Conduction in the AV Junction......Page 477
Concealed Conduction of Atrial Impulses into the Bundle Branch during Atrial Flutter and Atrial Fibrillation......Page 478
Gap Phenomenon......Page 480
References......Page 483
20 Ventricular Preexcitation (Wolff-Parkinson-White Syndrome and Its Variants)......Page 486
PR Interval......Page 487
Clinical Significance......Page 488
Tachyarrhythmias......Page 490
Atrial Fibrillation and Atrial Flutter......Page 498
Electrophysiologic Properties of the APs......Page 499
Anatomic Findings: Localization of the AP by Routine ECG......Page 500
Correlation of the Location of an AP and Electrophysiologic Properties......Page 503
Reentrant Tachycardia Associated with a Short PR Interval and Lown-Ganong-Levine Syndrome......Page 504
Mahaim-Type Preexcitation......Page 505
Atriofascicular Tracts......Page 506
Fasciculoventricular Fibers......Page 507
Ventricular Hypertrophy, BBB, and MI in the Presence of the WPW Pattern......Page 508
Radiofrequency Ablation of APs......Page 509
References......Page 511
21 Effect of Drugs on the Electrocardiogram......Page 514
Classification......Page 515
Class II Action......Page 516
Proarrhythmic Effects of Antiarrhythmia Drugs......Page 517
Procainamide......Page 518
Lidocaine, Mexiletine, Tocainide, Phenytoin......Page 519
Amiodarone and Dronedarone......Page 520
Calcium Channel-Blocking Agents: Verapamil and Diltiazem......Page 524
Psychotropic Drugs (Phenothiazines, Tricyclic Antidepressants, Lithium)......Page 525
Digitalis......Page 527
The More Common Arrhythmias......Page 529
Epinephrine, Norepinephrine, Isoproterenol......Page 531
Anesthetic and Analgesic Agents......Page 532
Antiparasitic Drugs......Page 533
References......Page 534
ECG Manifestations of Hyperkalemia......Page 537
ECG Manifestations of Hypokalemia......Page 543
Arrhythmogenic Effects......Page 546
Calcium......Page 547
Hypercalcemia......Page 548
Hypocalcemia......Page 549
Magnesium......Page 551
Hypothermia......Page 552
Central Nervous System Diseases......Page 554
References......Page 557
Secondary T Wave Abnormalities......Page 560
Ischemic and Postischemic T Wave Abnormalities......Page 561
Myocardial Disease Processes......Page 562
Diffuse (\"Global\") T Wave Inversion......Page 563
Isolated T Wave Inversion in Adults......Page 564
Hyperventilation......Page 565
Orthostatic Abnormalities......Page 566
Posttachycardia Abnormalities......Page 567
Right Ventricular Pacing......Page 568
T Wave Abnormalities Reversed by an Increase in Heart Rate......Page 569
Concomitant ST-T Abnormalities......Page 570
Computerized Analysis of T Wave Morphology and Spatial Orientation of the T Wave......Page 571
References......Page 572
Prolonged QT Interval......Page 574
Congenital Long QT Syndrome......Page 575
Obesity, Weight Loss, Dieting......Page 577
Predictive Value of QT Interval in Heart Disease......Page 578
Miscellaneous Conditions......Page 579
Increased Amplitude of Upright U Wave......Page 580
T Wave and U Wave Fusion in the Presence of a Prolonged QT Interval......Page 581
Nomenclature for Prolonged QT Interval in the Presence of Suspected T Wave and U Wave Fusion......Page 583
Alternans of Conduction......Page 584
Bundle Branches and Distal Conduction System......Page 585
Alternans Associated with Myocardial Ischemia......Page 586
References......Page 587
Reversal of Left Arm and Left Leg Cables......Page 591
Reversal of Right Arm and Right Leg Cables......Page 593
Reversal of Left Arm and Right Leg Cables......Page 595
Reversal of Both Arm Cables with Their Corresponding Leg Cables......Page 596
Misconnection of Precordial Lead Cables......Page 597
Recognition of Lead Misplacement: Summary......Page 598
Artifacts......Page 599
References......Page 602
Pacemakers Components......Page 603
Pacemaker Stimulus Artifact......Page 604
Atrial Pacing......Page 606
Pacing Modes......Page 607
Atrial Synchronous Ventricular Inhibited Pacing (VDD)......Page 608
Ventricular Pacing......Page 609
VOO Pacing......Page 610
VVI Pacing......Page 611
VVT Pacing......Page 613
Dual-Chamber Pacing......Page 614
AV Sequential Pacing......Page 615
Dual-Chamber Pacing and Sensing with Inhibition and Tracking: AV Universal Pacing (DDD)......Page 617
Magnet Mode......Page 619
Wenckebach Pacemaker Response......Page 620
Pacemaker Circus Movement Tachycardia......Page 621
Overdrive Suppression......Page 623
Adaptive AV Delay, Rate Hysteresis, Fallback Response, Rate Smoothing, Rate-Responsive AV Delay, Mode Switching, Autocapture......Page 624
Pacing Failure......Page 626
Undersensing......Page 627
Abnormal Latency......Page 628
ECG Signs of Malfunction of the AV Universal (DDD) Pacemakers......Page 629
Pacemaker Syndrome......Page 630
Diagnosis of MI during Ventricular Pacing......Page 631
Abnormally Wide QRS Complex......Page 632
References......Page 633
27 Ambulatory Electrocardiography......Page 636
Heart Rate......Page 638
Tachyarrhythmias......Page 639
Correlation with Symptoms of Palpitations, Dizziness, and Syncope......Page 640
Clues to the Arrhythmia Mechanism......Page 642
Evaluation of Ischemic Episodes......Page 644
Conduction Abnormalities......Page 645
Evaluating the Efficacy of Drug Treatment......Page 646
Heart Rate Variability......Page 647
References......Page 648
Heart Rate......Page 651
QRS Complex: Morphology, Duration, and Axis......Page 653
Q Waves......Page 654
ST Segment......Page 655
QT Interval......Page 658
References......Page 659
Right Atrial Enlargement......Page 662
Right Ventricular Hypertrophy......Page 663
Left Ventricular Hypertrophy......Page 667
QT Interval Prolongation......Page 668
Abnormal Q Waves......Page 670
References......Page 673
Atrial Septal Defect and AV Septal Defect......Page 675
Ventricular Septal Defect......Page 678
Patent Ductus Arteriosus and Aortopulmonary Window......Page 679
Aortic Stenosis......Page 681
L-Transposition of the Great Vessels......Page 682
d-Transposition of the Great Vessels......Page 684
Tetralogy of Fallot......Page 685
Pulmonary Atresia with Intact Ventricular Septum......Page 688
Ebstein\'s Anomaly of the Tricuspid Valve......Page 689
Tricuspid Atresia......Page 690
Single Ventricle......Page 692
References......Page 693
Sinus Rhythms......Page 698
Atrial Arrhythmias......Page 701
AV Junctional Arrhythmias......Page 705
AV Reentrant Arrhythmias......Page 709
Ventricular Arrhythmias......Page 711
AV Block......Page 717
References......Page 719
INDEX......Page 725