Comprehensive Electrocardiology, Second Edition (4-Volume Set)

Comprehensive Electrocardiology, Second Edition [4-Volume Set] (Springer Reference)......Page 1
Front-matter......Page 2
Title page......Page 4
Copyright......Page 5
Editors-in-Chief......Page 6
Preface......Page 8
Table of Contents......Page 10
List of Contributors......Page 14
1 The Coming of Age of Electrocardiology......Page 20
1.2 The Groundwork for Electrocardiography......Page 23
1.3 The Beginnings of Modern Electrocardiogrophy......Page 28
1.4 Analysis of Cardiac Rhythm......Page 29
1.5 Clinical Development of Electrocardiography......Page 32
1.6 The American Connection......Page 34
1.7 Vectorcardiography......Page 39
1.8 Lead Theory......Page 42
1.9 Electrocardiographic Mapping......Page 49
1.10 Activation of the Heart......Page 51
1.11 Arrhythmias, Conduction Defects and Sudden Death......Page 54
1.12 Technical Advances......Page 55
References......Page 63
2 Introductory Physics and Mathematics......Page 68
A.1 Introduction......Page 70
2.2.4 Scalar Product of Two Vectors......Page 71
2.2.4.1 Vector Product of Two Vectors......Page 72
2.2.6 Gradient......Page 73
2.2.7 Divergence......Page 75
2.2.9 Laplacian......Page 76
2.2.10 Vector Identities......Page 77
2.2.11.1 Divergence and Laplacian in Cylindrical Coordinates......Page 78
2.2.12 Solid Angle: Definition and Theory......Page 79
2.3.1 Coulomb's Law......Page 81
2.3.2 Electric Field......Page 82
2.3.3 Gauss' Flux Theorem......Page 83
2.3.4 Electric Scalar Potential......Page 84
2.4 Electric Current Flow in Conductive Media......Page 85
2.4.1 Ohm's Law of Conductivity......Page 86
2.4.2 Tissue Impedance......Page 87
2.4.3 Quasistatic Conditions......Page 88
2.5 Current Sources......Page 89
2.5.1.1 Monopole......Page 90
2.5.1.2 Dipole......Page 91
2.5.2 Surface Source Densities......Page 92
2.5.2.1 Monopole Layer; Monolayer......Page 93
2.5.2.2 Dipole Layer; Double Layer......Page 94
2.5.3 Volume Source Densities......Page 95
2.6 Potential Fields in Inhomogeneous Media......Page 96
2.6.1.1 Basic Formulation......Page 97
2.6.2 Method of Images......Page 98
2.6.2.1 Inferences......Page 99
2.6.3.1 General Solution of Laplace's Equation; Spherical Harmonics......Page 100
2.6.3.2 Application: Current Dipole Inside a Bounded Sphere......Page 101
2.6.3.3 Discussion......Page 103
2.6.4.1 Mathematical Preliminaries......Page 104
2.6.4.2 Equivalent Surface Sources......Page 105
Numerical Implementation......Page 106
2.6.4.4 Application of the BEM to Inhomogeneous Volume Conductors......Page 107
2.6.4.5 The BEM Used To Compute Potentials On The Heart Surface......Page 109
A.1.2.1 Vector Addition......Page 110
A.1.3 Matrices......Page 111
A.1.3.2 Multiplication and Matrices......Page 112
A.3.1 True Solutions......Page 113
A.3.2.1 Specific Notations......Page 114
A.4 The Singular Value Decomposition......Page 115
A.4.1 The Basic Statement......Page 116
A.4.2 Applications of the Decomposition......Page 117
A.5 Definitions and Notations......Page 118
GeneralReferences......Page 119
AppendixBibliography......Page 120
3 Cellular Electrophysiology......Page 124
3.1.1 Annotation Conventions......Page 126
3.2.1 Myocyte Structure and Relation to Excitation–Contraction Coupling......Page 127
3.2.2 Tissue Structure and Relation to Global Heart Excitation......Page 128
3.3.2 Special Routes for Ion Permeation: Ion Channels......Page 129
3.3.4 Changes in Membrane Selective Permeability: Ion Channel Gating......Page 130
3.4 How Membrane Current Affects Membrane Potential......Page 131
3.6 Resting Membrane Potential......Page 132
3.8.1 The Cardiac Action Potential Contour......Page 133
3.8.2.1 Large Hearts have Long APs......Page 135
3.8.2.2 Where Stability and Flexibility Meet......Page 136
3.9 Pacemaker Function......Page 138
3.9.1 Currents Underlying Diastolic Depolarization and its Autonomic Modulation......Page 140
3.9.2 Intracellular Ca2+-Dynamics may Contribute to Pacemaking......Page 142
3.9.4 Functional Inhomogeneity in the Sinus Node......Page 143
3.10 Ionic Homeostasis and Electrical Activity......Page 145
3.11.2 Different Delayed Rectifier Currents Underlie Repolarization in the Atria......Page 146
3.12 Cardiac Channel Proteins......Page 147
3.13.1 General Mechanism of Propagation......Page 148
3.13.2 Conduction Velocity......Page 149
3.14 Mathematical Models......Page 150
3.14.1 The Seminal Hodgkin-Huxley Model......Page 151
3.14.2 Early Cardiac Cell Models (1960–1989)......Page 152
3.14.4 First-Generation and Second-Generation Models......Page 153
3.14.5 Deterministic, Stochastic and Markov Models......Page 155
3.14.7 Multicellular Simulations......Page 156
References......Page 157
4 Activation of the Heart......Page 164
4.2 The Sinoatrial Node......Page 165
4.3 Subsidiary Pacemakers with Normal Automaticity......Page 167
4.4 Atrial Activation......Page 169
4.7 Activation of the Atrioventricular Nodal Area......Page 170
4.8 Dual Atrioventricular Nodal Pathways and Reentry......Page 173
4.10 Ventricular Activation......Page 174
4.11 The Purkinje-Muscle Junction......Page 177
4.12 The M Cell......Page 178
References......Page 179
5 Genesis of the Electrocardiogram......Page 186
5.2.1 Electrocardiography......Page 187
5.2.2 Electrophysiology......Page 188
5.2.3 Synthesis......Page 189
5.3.1 Source Character of a Single Fiber......Page 190
5.3.2 Extracellular Current Flow......Page 192
5.3.4 Potential Field Around a Single Fiber......Page 193
5.3.5 Source Description at Depolarization Wave Fronts; Uniform Double Layer Theory......Page 194
5.3.6 The Effects of the Geometry of Torso Boundary and Inhomogeneous Tissue Conductivity......Page 195
5.3.7 Depolarization Summary......Page 196
5.4.1 Cautions......Page 197
5.5 P Wave......Page 198
5.7 QRS Complex......Page 199
5.8 ST Segment......Page 201
5.9.3 Intrinsic, Primary and Secondary T Waves......Page 203
5.9.4 Ventricular Gradient......Page 204
5.11 Vectorial and Other Interpretations of the ECG......Page 206
References......Page 207
6 Macroscopic Source Descriptions......Page 212
6.2 Estimation of Macroscopic Cardiac Sources......Page 213
6.3.1 The Single Cell......Page 214
6.3.2 The Single Fiber......Page 216
6.3.3 Electrograms Generated by a Single Fiber......Page 218
6.4 Macroscopic Source Descriptions During Depolarization......Page 220
6.4.1.2 A Hemisphere......Page 221
6.4.1.4 A Dispersed Double Layer......Page 224
6.4.2.1 Infinite Medium Potentials......Page 226
6.4.2.2 The Effect of Inhomogeneous Conductivity; the Brody Effect......Page 228
6.4.2.3 Bounding the Medium; the Influence of the Reference......Page 230
6.4.2.4 Discussion......Page 232
6.4.3 Electrophysiology Based UDL Parameters......Page 233
6.4.3.2 Parameters of the UDL Source Estimated from Measured Potentials......Page 234
6.4.4 Validity of the UDL Source Model......Page 236
6.4.4.1 The UDL Model Criticized......Page 237
6.4.4.2 The Strength of the UDL Source Model......Page 238
6.5.1 The Axial Model......Page 239
6.5.1.1 Potentials Generated by the Axial Model......Page 240
6.5.2 The Oblique Dipole Model......Page 241
6.6 Evaluation......Page 242
References......Page 243
7 The Equivalent Double Layer: Source Models for Repolarization......Page 246
7.2 Linking the UDL to the EDL......Page 247
7.2.1 Discussion......Page 249
7.3.1 Linking EDL Source Strength to Transmembrane Potentials......Page 250
7.3.2 Discussion......Page 251
7.4.1 Source Specification......Page 252
7.4.2 The Transfer Function B......Page 253
7.4.3 Standard 12-Lead ECG......Page 254
7.4.5 Discussion......Page 255
7.4.6 T Waves as Explained in Standard Text Books......Page 256
7.5 EDL Based Inferences for Basic STT Parameters......Page 258
Appendix: The EDL and Bidomain Theory......Page 259
Equal Anisotropy Ratio Assumption......Page 260
Evaluation......Page 263
8 The Forward Problem of Electrocardiography......Page 266
8.1 Introduction......Page 268
8.2.1 Cellular Electrophysiology......Page 270
8.2.2 Tissue and Whole Organ Experiments......Page 271
8.2.2.1 Lead Systems and Electrode Arrays......Page 272
8.2.3 Physical Models and Phantoms of the Thorax......Page 274
8.3.1 Models of Cardiac Myocytes......Page 278
8.3.1.1 Biophysically Based Models......Page 279
8.3.2.2 Bidomain Method......Page 281
8.4.1 Physiology Background......Page 284
8.4.2 Cellular Automata......Page 285
Huygens' Principle Models......Page 287
8.4.3 Eikonal Curvature......Page 288
8.4.4 FitzHugh and Nagumo......Page 289
8.4.6 Applications......Page 290
8.5 Models of Volume Conductor Potentials......Page 291
8.5.3 Discrete Source Models......Page 292
8.5.4 Cardiac Surface Potential Models......Page 293
8.6.1 Introduction......Page 294
8.6.2 The Finite Difference Method (FDM)......Page 296
8.6.3 The Finite Element Method (FEM)......Page 297
8.6.4 The Boundary Element Method (BEM)......Page 300
8.6.5 Geometric Modeling......Page 301
Software for Volume Conductor Problems......Page 305
8.7.2 Computability......Page 308
8.7.4 Mechanical and Chemical Interactions......Page 309
8.8 Summary......Page 310
9 The Inverse Problem of Electrocardiography......Page 318
9.1 Introduction......Page 319
9.2 Inverse Problem Formulation......Page 322
9.2.1 Including Time in the Formulation......Page 323
9.2.2 The Inverse Problem......Page 324
9.3 Potential-Based Inverse Solutions from Body Surface Measurements......Page 326
9.3.1 Tikhonov Regularization......Page 327
9.3.2 Truncated SVD (TSVD)......Page 328
9.3.3 Truncated Iterative Approaches......Page 329
9.3.4 Statistical Approaches......Page 330
9.3.6 Spatio-Temporal Approaches......Page 331
9.3.6.1 Spatio-Temporal Constraints with Heart Surface Potential Models......Page 332
9.3.6.2 Spatio-Temporal Constraints with Surface Transmembrane Potential Models......Page 337
9.3.7 Imaging Transmural Potentials......Page 338
9.4 Fiducial-Time Based Inverse Algorithms......Page 339
9.5 Inverse Solutions from Intracavitary Measurements......Page 345
9.6.2 L-Curve Criterion......Page 346
9.6.4 Zero-Crossing Criterion......Page 347
9.7.1 Simulation Studies......Page 348
9.7.1.2 Numerical Solutions......Page 349
9.7.2 Experimental Validation......Page 350
9.7.3.1 Inverse Solutions Computed from Body Surface Potentials......Page 352
9.7.3.2 Validation of Endocardial Solutions......Page 353
9.8 Current Status and Futures Direction......Page 355
10 Lead Theory......Page 366
10.1.2 Volume Conductor Theory of Electrocardiographic Leads......Page 367
10.2.1 Assumptions Concerning Cardiac Bioelectric Sources......Page 368
10.2.2 Assumptions Concerning the Human Torso......Page 369
10.2.3 Definition of Electrocardiographic Lead......Page 370
10.3.1 Definition......Page 372
10.3.2 Scalar Product and its Geometrical Interpretation......Page 373
10.3.5 Burger Triangle......Page 374
10.3.6 Einthoven's Triangle......Page 375
10.3.7 Composite Leads with Passive Networks......Page 377
10.3.8 Composite Leads with Active Networks......Page 378
10.4.1 Image Surface of Bounded Two-Dimensional Conductor......Page 379
10.4.2 Image Surface of Bounded Volume Conductor......Page 380
10.4.3 Image-Surface Definitions......Page 385
10.4.4 Bibliographic Notes......Page 386
10.5.1 Lead-Field Derivation......Page 387
10.5.2 Lead-Field Definition......Page 388
References......Page 391
11 Lead Systems......Page 394
11.2.1 Bipolar Limb Leads......Page 396
11.2.1.1 Limb Electrode Positions......Page 397
11.2.2 Unipolar Limb Leads......Page 398
11.2.3 Augmented Unipolar Limb Leads......Page 399
11.2.4 Unipolar Chest Leads......Page 400
11.2.5 Additional Chest Leads......Page 402
11.2.6 12-Lead ECG Relationships......Page 403
11.3.1 Bipolar Chest Leads......Page 405
11.3.2 Nehb Leads......Page 407
11.4 Orthogonal-Lead Systems......Page 408
11.4.1 Uncorrected Orthogonal-Lead Systems......Page 409
11.4.2.1 Frank System......Page 410
11.4.2.3 Hybrid-Lead System......Page 412
11.5.1 The Derived 12 Lead ECG......Page 415
11.5.2 The EASI Lead System......Page 416
11.5.3 Reduced Lead Sets......Page 417
11.6 Derived Orthogonal-Lead ECG......Page 419
11.7 The Vectorcardiogram......Page 422
11.8 Derived Vectorcardiogram –12 Lead Vectorcardiography......Page 423
11.9 Interrelationship of the 12-Lead and XYZ Lead Electrocardiograms......Page 424
11.10 Nomenclature......Page 427
11.11 Exercise ECG Lead Systems......Page 429
11.12 ECG Monitoring in Hospital......Page 433
11.13 Body-Surface Mapping Lead Systems......Page 434
11.14.1 Transmural and Epicardial Mapping......Page 435
11.15 Ambulatory Monitoring Leads......Page 436
11.16 Esophageal Leads......Page 438
11.18 Comparative Electrocardiography......Page 439
References......Page 441
12 ECG Instrumentation: Application and Design......Page 446
12.2.1 Formation of the ECG......Page 448
12.2.2 Formation of ECG Wave Forms......Page 449
12.2.4 Characteristics of Composite ECG Signals......Page 451
12.3 Biopotential Sensors......Page 452
12.3.1.1 Electrochemical Reactions......Page 453
12.3.1.2 Impedance of the Interface......Page 454
12.3.2 Polarizable and Non-polarizable Biopotential Sensors......Page 456
12.3.2.1 Polarizable Electrodes......Page 457
12.3.3 The Sensor–Skin Interface......Page 458
12.3.3.1 Anatomical Details of the Skin......Page 459
12.3.3.3 Practical Considerations......Page 461
12.3.4.1 Metal Electrodes......Page 463
12.3.4.2 Pre-Gelled Galvanic Electrochemical ECG Sensors......Page 464
12.3.4.4 Challenges Encountered in the Current Practice of ECG Monitoring......Page 466
12.3.5.1 Principle of Operation......Page 467
12.3.5.2 Technology......Page 468
12.3.5.4 Clinical Testing......Page 469
12.3.6 Active ECG Sensors......Page 470
12.3.7 Paste-Less Electrodes......Page 473
12.3.7.1 Biopotential Sensors with Spiked Electrodes......Page 475
12.3.8.1 AC Impedance......Page 476
12.3.8.4 Defibrillation Overload Recovery......Page 477
12.3.9.4 ECG Cables and Lead Wire Standards......Page 478
12.3.10.1 Low Invasive Measurement of Electrocardiogram for Newborns and Infants......Page 479
12.3.11.1 A Prototype Biopotential Sensor Shirt......Page 480
12.3.11.2 High Impedance Biopotential Optical Sensor......Page 481
12.3.11.3 Electroactive Fabrics and Wearable ECG Devices......Page 483
12.4 ECG Signal Recording and Basic Processing......Page 484
12.4.1.1 Front-End of the Amplifier......Page 485
12.4.1.2 Common Mode Rejection......Page 486
12.4.1.4 The Highpass Filter......Page 487
12.4.1.6 Strategies for Ensuring a High Signal Quality ECG Acquisition......Page 488
Sampling Rate......Page 489
Sampling Theorem and Analog Filters......Page 490
Basic Digital Signal Processing......Page 491
Additional Filtering......Page 492
Recursive LP Filter......Page 493
Lowpass Moving Average Filter......Page 494
Baseline Correction/Definition......Page 495
References......Page 497
13 The Normal Electrocardiogram and Vectorcardiogram......Page 502
13.2.1 Sampling Methods......Page 504
13.2.2 Cardiovascular Screening......Page 505
13.2.3.1 Sample Size......Page 506
13.2.3.2 Normal Ranges......Page 507
13.2.3.3 Angular Data......Page 510
13.2.3.4 Sensitivity and Specificity......Page 511
13.2.4 Methods of Measurement......Page 515
13.2.5 Use of Computers......Page 519
13.3.2 Repeat Variation......Page 520
13.4.1 Age......Page 522
13.4.2 Sex......Page 524
13.4.3 Race......Page 525
13.4.5 Physical Fitness......Page 527
13.4.6 Heart Position......Page 529
13.5.1 Evolutionary Development of the Electrocardiogram......Page 531
13.5.2 Examples of the Normal Electrocardiogram......Page 532
13.6.1 Examples of the Normal Vectorcardiogram......Page 536
13.7.1 Electrocardiographic Parameters......Page 537
13.7.2 P Wave......Page 540
13.7.4 QRS Complex......Page 541
13.7.5 Additional Chest Leads......Page 545
13.7.7 ST-T Wave......Page 548
13.7.8 Time Intervals......Page 552
13.7.9 QT Interval......Page 555
13.8.1 Minnesota Code......Page 558
13.8.2 Washington Code......Page 559
13.8.3 Punsar Code......Page 560
13.10 Acknowledgement......Page 561
14 Conduction Defects......Page 566
14.2 Intra-Atrial Conduction Defects......Page 568
14.2.1 Electrical Physiopathology and ECG/VCG Patterns......Page 569
14.3 Intraventricular Conduction Defects......Page 571
14.3.1 Fascicular Blocks......Page 573
14.3.1.1 Left Anterior Fascicular Block......Page 574
14.3.1.2 Left Posterior Fascicular Block......Page 577
14.3.1.3 Left Median (Centroseptal) Fascicular Block......Page 580
14.3.2.1 Incomplete Right Bundle Branch Block......Page 581
14.3.2.2 Incomplete Left Bundle Branch Block......Page 584
14.3.2.4 Complete Right Bundle Branch Block......Page 586
14.3.2.5 Complete Left Bundle Branch Block......Page 589
14.3.3.1 Right Bundle Branch Block and Left Anterior Fascicular Block......Page 594
14.3.3.2 Right Bundle Block and Left Posterior Fascicular Block......Page 597
14.3.3.3 Left Bundle Branch Block with Left Fascicular Blocks......Page 599
14.3.3.4 Progression of Bifascicular Blocks (and Other Intraventricular Conduction Defects)to Advanced AV Block......Page 600
14.3.4.3 Nonspecific IV Block......Page 601
14.3.5 Clinical Overview of Intraventricular Conduction Defects......Page 602
14.4.1 Definition......Page 603
14.4.2 Anatomic Basis......Page 604
14.4.3.1 Classification......Page 605
14.4.3.2 Associated Arrhythmias......Page 608
14.4.3.4 Diagnostic Difficulties......Page 610
14.4.4.1 Short PR Syndromes......Page 611
14.4.4.2 Nodoventricular Connections......Page 612
14.5.1 Classification......Page 613
14.5.2 Molecular Genetics......Page 614
14.5.6 Electrophysiological Evaluation......Page 615
References......Page 616
15 Enlargement and Hypertrophy......Page 624
15.1 Introduction......Page 626
15.1.1 Anatomic Standards for Hypertrophy......Page 627
15.1.2 Echocardiographic Standards for Hypertrophy......Page 628
15.2.4 Associated Diseases......Page 630
15.2.6 Theoretical Considerations......Page 631
15.3.1 ECG Criteria......Page 632
15.3.1.1 Lewis Index......Page 633
15.3.1.3 McPhie Criterion......Page 634
15.3.1.4 Romhilt–Estes Point Score System......Page 635
15.3.1.5 Kansal Criteria......Page 637
15.3.1.6 Cornell Multivariate Score and Voltage......Page 638
15.3.1.8 Voltage-Duration Product and Time-Voltage Area Criteria......Page 639
15.3.3 ECG Criteria Summary......Page 640
15.3.4 Orthogonal-Lead and VCG Criteria......Page 641
15.4.2 Athlete's Heart......Page 642
15.4.4 Bundle Branch Block and LVH......Page 643
15.4.5 Regression......Page 644
15.4.6 Prognosis of ECG LVH......Page 645
15.4.7 Prevalence......Page 646
15.5.1 ECG Criteria......Page 647
15.5.3 S1S2S3 Syndrome......Page 650
15.5.4 Chronic Obstructive Pulmonary Disease......Page 651
15.5.5 Orthogonal-Lead and VCG Criteria......Page 652
15.6.2 Right Bundle Branch Block and RVH......Page 653
15.7.1 ECG Criteria......Page 655
15.7.2 Vectorcardiogram......Page 657
15.8 Atrial Enlargement or Overload......Page 658
15.8.1 Left Atrial Abnormality......Page 659
15.8.3 Right Atrial Abnormality......Page 661
References......Page 663
16 Myocardial Infarction......Page 670
16.1.2 Historical and Future Perspective......Page 672
16.1.2.2 Current and Future Perspective......Page 673
16.1.3.1 Myocardial Subdivisions......Page 674
16.1.3.2 Extent and Sites of Myocardial Infarction and Related Coronary Artery Occlusions......Page 676
16.1.3.3 Myocardial Fibrosis (Multifocal Infarct): Etiology and Common Terms......Page 677
16.1.4.1 Left Anterior Descending (LAD) Coronary Artery Occlusion......Page 678
16.1.4.4 Right Coronary Artery (RCA) Occlusion......Page 680
16.2.1 Geometry and Anatomy of Typical Myocardial Infarcts......Page 681
16.2.2 Sensitivity of Conventional ECG Criteria for Infarcts......Page 683
16.2.3 His-Purkinje Relationship to Coronary Occlusion and Myocardial Infarction......Page 684
16.2.4.1 Computer Simulation of Ventricular Excitation......Page 685
16.2.4.2 Simulation of Ventricular Excitation and the ECG Infarct Scoring System......Page 688
16.2.5 Ventricular Repolarization and Myocardial Injury, Ischemia, and Infarction......Page 689
16.2.5.1 Computer Simulation of Repolarization......Page 690
16.3.2 Infarct Size, Left Ventricular Function, and Prognosis......Page 694
16.3.3 Infarct Size and Left Atrial Overload......Page 695
16.3.5 Computer Simulations and QRS Infarct Size Scoring Systems for ECG and VCG......Page 696
16.3.5.1 Validation Studies......Page 698
16.3.6 Methods for the 12 Lead ECG QRS MI Size Scoring System, Manual......Page 701
16.3.6.2 Rigorous Waveform Definitions......Page 702
16.3.6.4 Guidelines for QRS Scoring......Page 703
16.3.7 Automated ECG Analysis Programs and QRS Score for Infarct Size......Page 705
16.4.1 Acute Myocardial Infarction, Evolving Changes of Injury, Ischemia and Necrosis......Page 706
16.4.2 Acuteness, Severity and Extent of Ischemia......Page 713
16.4.2.1 Acuteness of Ischemia......Page 714
16.4.2.2 The 24-Lead ECG and Acute Myocardial Infarction......Page 716
16.4.2.3 Severity of Ischemia......Page 719
16.4.2.4 Extent of Ischemia (Myocardium at Risk)......Page 721
16.4.3.1 Spectrum of ECG/VCG Changes from Acute LAD Occlusion......Page 724
16.4.3.2 Anterior Infarct with Associated Left Anterior-Superior Fascicular Block, LAFB......Page 725
16.4.4 Non-Dominant Circumflex Occlusion and Typical Posterolateral Infarcts......Page 727
16.4.5 Right Coronary Occlusion and Typical Inferior Infarcts......Page 729
16.4.5.1 Right Ventricular Infarction......Page 737
16.4.6 Dominant Left Circumflex Occlusion and Typical Posterolateral Inferior Infarcts......Page 740
16.4.7 Differential Diagnosis of Poor R-Wave Progression in Leads V1–V6......Page 741
16.4.9 Differential Diagnosis of Abnormal Inferior Q Waves and ST Vectors......Page 742
16.4.10 Summary of Electrocardiographic Changes Following Acute Coronary Occlusion......Page 743
16.5.1 Essential Principles......Page 744
16.5.3.1 Incidence of Preexisting or Recent Onset RBBB......Page 745
16.5.4 Myocardial Infarction and RBBB......Page 748
16.5.4.3 Circumflex Occlusion, Posterolateral Infarction and RBBB......Page 749
16.5.5.1 Secondary ST-T of LBBB Modified by a Local Acute Myocardial Infarction......Page 750
16.5.5.2 Activation Sequence in LBBB and Regional Healed Infarcts......Page 751
16.5.5.3 LAD Occlusion, Anterior Infarction and LBBB......Page 755
16.5.5.5 Circumflex Coronary Occlusion, Posterolateral Infarction and LBBB......Page 758
16.6 Future Advances in ECG Diagnosis and Imaging of Infarction......Page 759
Appendixes......Page 760
References......Page 761
17 Ventricular Repolarization: Theory and Practice in Non-Ischemic Myocardium......Page 766
17.1 Introduction......Page 768
17.2.2 Deviations from the Baseline......Page 769
17.2.2.1 ST Deviations in the Absence of Ischemia (Secondary Repolarization Changes)......Page 770
17.2.2.3 Depression of the ST Segment......Page 771
17.2.2.4 Elevation of the ST Segment......Page 772
17.2.2.6 ST Segment Elevation-Normal Variant and Acute Pericarditis......Page 773
17.2.2.7 ST Segment: Effect of Gender and Age......Page 774
17.2.2.8 Alternans of the Depressed and the Elevated ST Segment......Page 775
17.3.1 General Considerations: Ventricular Gradient......Page 776
17.3.2 Normal Configuration and Direction......Page 780
17.3.3 Classification of T-Wave Abnormalities......Page 784
17.3.4 Secondary T-Wave Abnormalities......Page 785
17.3.5.2 Cardiac Glycosides......Page 786
17.3.5.3 Class IA Antiarrhythmic Drugs......Page 788
17.3.5.5 Phenothiazines......Page 789
17.3.5.6 Hyperkalemia......Page 790
17.3.5.8 Combination of Abnormal Potassium and Calcium Concentration......Page 791
17.3.6.1 Syndrome X......Page 792
17.3.6.3 Other T-Wave Abnormalities Attributed to Myocardial Damage......Page 793
17.3.6.4 ECG Pattern of Cerebrovascular Accident......Page 794
17.3.6.6 Giant and Global Negative T Waves......Page 796
17.3.6.7 Isolated T-Wave Inversion of Adults......Page 797
17.3.6.8 Hypothyroidism......Page 798
Orthostatic Abnormalities......Page 799
Post-tachycardia Abnormalities......Page 800
Abnormalities Produced by Ventricular Pacing......Page 801
Abnormalities Following Preexcitation and Left Bundle Branch Block. Cardiac ``Memory''......Page 802
Detection of T-Wave Abnormalities Associated with Rapid Heart Rate......Page 803
Detection of Rapidly Reversible Rate-Independent T-Wave Abnormalities......Page 804
17.3.7 T Wave Alternans......Page 806
17.3.8 ST–T Abnormalities......Page 807
17.4.2 Relation Between the U Wave and Other Deflections of the ECG......Page 808
17.4.5 The Negative U Wave......Page 809
17.4.6.1 Repolarization of Purkinje Fibers......Page 811
17.4.6.3 Mechanoelectrical Coupling......Page 812
18 Ventricular Repolarization in Myocardial Ischemia and Myocardial Infarction: Theory and Practice......Page 822
18.3 ST Segment Deviations Arising from Epicardial or Endocardial Injury......Page 824
18.4.1 Anterior Wall Myocardial Infarction and Occlusion of Left Anterior Descending (LAD)Coronary Artery......Page 826
18.5 Inferior Wall MI......Page 828
18.6 Differences Between Inferior MI Caused by Right and Left Circumflex Occlusion......Page 832
18.8 Acute Injury Pattern in the Right Precordial Leads and Right Ventricular Infarctionand Other Causes......Page 833
18.10 Coronary Spasm, Unstable Angina Pectoris, and Non-Q-Wave MyocardialInfarction......Page 834
18.11 ST Segment Changes as a Guide to Thrombolytic and PercutaneousIntervention Therapy......Page 835
18.13 Persistent ST Segment Elevation After Myocardial Infarction......Page 836
18.16.1 Other Causes of ST Segment Elevation......Page 838
18.16.2 Reciprocal ST Changes in Acute Myocardial Infarction......Page 839
18.19 Postischemic T Wave Abnormalities......Page 840
18.21 Prognostic Implications of Abnormal Repolarization During Acute Myocardial Infarction......Page 842
References......Page 844
19 The QT Interval......Page 852
19.2.1 Long QT Syndrome (LQTS) as a Paradigm for Understanding Ventricular Repolarization......Page 853
19.2.2 Ion-Channel Function and Arrhythmogenesis......Page 854
19.3.1 QT Interval Measurement......Page 856
19.3.2 Lead Selection for QT Duration......Page 857
19.3.4 Normal QTc Values for Age and Gender......Page 858
19.3.5 QT Prolongation and Risk of Cardiac Arrhythmias and Mortality......Page 859
19.3.6 Changes in T wave Morphology......Page 860
19.4 Drug-Induced QT Prolongation......Page 861
19.5 Dynamics of QT Interval......Page 863
19.5.1 Methods to Assess QT/RR Dynamics......Page 865
19.5.2 Clinical Factors Influencing QT/RR Slope......Page 866
19.5.3 Prognostic Value of QT/RR Slopes......Page 867
19.6.1 Methods of QT Variability Assessment......Page 872
19.6.2  Clinical Factors Influencing QT Variability......Page 873
19.6.3  Prognostic Value of QT Variability......Page 874
19.7 Summary......Page 876
References......Page 877
20 Miscellaneous Electrocardiographic Topics......Page 882
20.2.1.1 P Wave, QRS Complex, and Conduction Disturbance......Page 886
20.2.1.2 ST Segment and T Wave......Page 887
20.2.2.2 ST Segment and T and U Waves......Page 890
20.2.2.3 Conduction and Impulse Generation......Page 892
20.2.3.3 Conduction and Impulse Generation......Page 893
20.2.8 pH......Page 895
20.3 Atmospheric Pressure Changes......Page 896
20.5.2 Hyperthermia......Page 897
20.6.1 Thyroid Heart Diseases......Page 898
20.6.2.1 Arrhythmias......Page 899
20.6.3 Hypothyroidism......Page 900
20.6.5 Hypothalamus and Pituitary Gland......Page 901
20.6.9 Diabetes Mellitus......Page 902
20.7.1 Cerebrovasular Accidents......Page 903
20.7.3 Neuromuscular Diseases......Page 904
20.8.1 Thoracic Skeletal Abnormalities......Page 905
20.8.2 Parenchymal Lung Diseases......Page 908
20.8.6 Pleural and Mediastinal Effusions......Page 909
20.8.8 Aortic Dissection......Page 910
20.9.2 Acute Cor Pulmonale and Pulmonary Embolism......Page 911
20.10 Mitral Valve Prolapse Syndrome......Page 912
20.11 Infectious Heart Diseases......Page 913
20.11.2 Chagas Disease......Page 914
20.12 Connective Tissue Diseases......Page 916
20.13.2 Dilated Cardiomyopathy......Page 917
20.13.3 Restrictive Cardiomyopathy......Page 920
20.14 Cardiac Transplantation......Page 921
20.15 Heart Injury......Page 923
20.16.1 Pericarditis......Page 925
20.16.3 Pericardial Tamponade......Page 926
20.18 Electrical Alternans......Page 927
20.19 Cardiac Memory......Page 928
20.20 Gastrointestinal Disease......Page 930
20.23 Non-Specific ST-T Changes......Page 932
20.24.2 Positive Giant T Waves......Page 933
20.24.3.2 Ventricular Hypertrophy and Hypertrophic Cardiomyopathy......Page 936
20.24.3.4 Electrolyte Abnormalities......Page 937
20.24.3.5 Sympathetic Nerves and Catecholamines......Page 938
20.24.4 Low Voltage ECG......Page 939
20.25.3 Heart Position......Page 940
20.25.4 Body Posture......Page 941
20.25.5 Respiration......Page 942
20.27 Pregnancy......Page 943
20.29.2 Alcohol......Page 946
20.29.4 Tobacco......Page 947
20.29.8 Poisons......Page 948
20.30.3 Athlete's Heart......Page 949
20.31.4 Belching, Nausea, Vomiting......Page 950
20.35 Race and Ethnicity......Page 951
20.36.3 ST Segment and T Waves......Page 952
20.36.4 Heart Rhythm and Conduction......Page 953
20.37.1 Improper Electrode Positioning......Page 954
20.37.2 Muscle Tremor and Other Movements During ECG Recording......Page 955
20.37.3 Inappropriate Damping of the Stylus of the ECG Recorder......Page 958
20.37.4 Wrong Speed or Wrong Switching During the ECG Recording......Page 959
20.37.5 Electric and Magnetic Fields......Page 961
20.37.6 Other Sources of Artifactual ECGs......Page 962
20.38 Automated ECG Interpretation......Page 964
20.39 New Ideas in Elecrocardiography......Page 965
21 The Electrocardiogram in Congenital Heart Disease......Page 988
21.1 Introduction......Page 992
21.2 Atrial Septal Defect (Ostium Secundum Type)......Page 993
21.2.2.1 RVH Criterion 1 – Direction of Inscription of QRS Vector Loops......Page 995
21.2.2.3 RVH Criterion 3 – Main or Mean QRS Horizontal Plane Vector to the Right......Page 997
21.2.2.4 RVH Criterion 4 – Main or Mean QRS Vector Abnormally Anterior......Page 998
21.2.2.5 RVH Criterion 5 – Mean QRS Vector in the Frontal Plane to the Right......Page 999
21.2.2.7 RVH Criterion 7 – A Terminal r or R in V4R and V1......Page 1000
21.2.2.11 RVH Criterion 11 – Abnormal Ratios of Specific Magnitudes......Page 1001
21.3 Atrial Septal Defect (Ostium Primum Type)......Page 1002
21.4 Single Atrium......Page 1003
21.5.1 RVH Criterion 1 in Pulmonic Stenosis......Page 1004
21.5.2 RVH Criterion 2 in Pulmonic Stenosis......Page 1005
21.5.4 RVH Criterion 7 in Pulmonic Stenosis......Page 1007
21.5.6 RVH Criteria 16 and 17 in Pulmonic Stenosis......Page 1008
21.6 Total Anomalous Pulmonary Venous Return to the Right Atrium......Page 1009
21.6.2 RVH Criterion 2 in TAPVR......Page 1010
21.7 Hypoplastic Left Ventricle Syndrome......Page 1011
21.8 Complicated Coarctation of the Aorta......Page 1012
21.9 Transposition of the Great Arteries with Intact Ventricular Septum......Page 1013
21.10 Tetralogy of Fallot......Page 1014
21.10.1 RVH Criterion 1 in TOF......Page 1015
21.10.4 RVH Criterion 16 and 17 in TOF......Page 1016
21.12 Nonrestrictive LV-RV Communication with Pulmonary Vascular Disease......Page 1017
21.13 Patent Ductus Arteriosus......Page 1018
21.13.1.1 LVH Criterion 1 – Direction of Inscription of QRS Vector Loops......Page 1020
21.13.1.3 LVH Criterion 3 – Abnormally Posterior Angle of the Main or Mean QRS Vector......Page 1021
21.13.1.6 LVH Criterion 6 – Increased Magnitude of Inferior QRS Vector......Page 1022
21.13.1.7 LVH Criterion 7 – Increased Magnitude of Posterior QRS Vector......Page 1023
21.13.1.10 LVH Criterion 10 – Increased Magnitude of R in aVL......Page 1024
21.13.1.13 LVH Criterion 13 – T-Wave Abnormality......Page 1025
21.14 Aortic Stenosis (Valvular)......Page 1027
21.14.1 LVH Criterion 1 in Aortic Stenosis......Page 1028
21.14.5 LVH Criterion 8 in Aortic Stenosis......Page 1030
21.14.7 LVH Criterion 13 in Aortic Stenosis......Page 1031
21.15 Aortic Stenosis (Fixed, Subvalvular)......Page 1032
21.17 Coarctation of the Aorta After Infancy......Page 1033
21.20 Congenital Aortic Regurgitation......Page 1034
21.22 Coronary Arterial Fistula......Page 1035
21.23 Hypoplastic Right Ventricle with Pulmonary Atresia......Page 1038
21.24 Hypoplastic Right Ventricle with Tricuspid Atresia......Page 1039
21.25.1 Left Ventricular Disease with Pulmonary Venous Hypertension......Page 1040
21.25.2.1 Ventricular Septal Defect......Page 1041
21.25.3 Biatrial Enlargement......Page 1043
21.25.4 Criteria for Biventricular Hypertrophy......Page 1046
21.25.4.1 BVH Criterion 1 – Direction of Inscription of QRS Vector Loops......Page 1047
21.25.4.2 BVH Criterion 2 – Decreased QRS Magnitude Posteriorly and/or to the Left,with a Large Terminal QRS Vector to the Right......Page 1048
21.25.4.3 BVH Criterion 3 – Increased Magnitude Anterior Along with Definite Evidence for LVH......Page 1049
21.25.4.5 BVH Criterion 5 – Katz-Wachtel phenomenon......Page 1050
21.25.4.7 BVH Criterion 7 – ST and T Abnormality......Page 1051
21.25.5.2 BVH Criterion 9 – Clockwise Inscription of the Frontal Plane in the Presence ofDefinite LVH......Page 1052
21.25.5.4 BVH Criterion 11 – Abnormally Superior Maximum QRS Vector in the Presence ofDefinite RVH......Page 1053
21.26 Atrioventricular Canal......Page 1054
21.27 Large PDA (and the Common A-P Window)......Page 1055
21.29 Ostium Primum ASD with Mitral Regurgitation......Page 1057
21.30 True Truncus Arteriosus......Page 1058
21.32 Coarctation of the Aorta Late in Infancy......Page 1059
21.33.1 Ventricular Inversion......Page 1060
21.33.2 Single Ventricle......Page 1063
21.33.3 Ebstein's Anomaly......Page 1064
21.33.4 Dextrocardia......Page 1065
21.33.5 Tetralogy of Fallot with Systemic-Pulmonary Shunt......Page 1067
21.33.6 Transposition of the Great Arteries with Large VSD......Page 1068
21.33.7 Anomalous Left Coronary Artery in the Infant......Page 1069
21.33.8 Postoperative RBBB, Left Anterior Hemiblock and LBBB......Page 1070
References......Page 1071
22 Electrocardiography in Adult Congenital Heart Disease......Page 1074
22.2.3 Situs Inversus and Heterotaxy Syndromes......Page 1075
22.2.6 Congenitally Corrected Transposition of the Great Arteries......Page 1077
22.3.1 Ostium Secundum Atrial Septal Defect......Page 1078
22.3.2 Ventricular Septal Defect......Page 1079
22.3.3 Atrioventricular Canal Defect......Page 1081
22.3.5 Pulmonary Stenosis......Page 1082
22.3.7 Ebstein's Anomaly......Page 1083
22.3.8 Surgically Corrected Tetralogy of Fallot......Page 1085
22.3.9 Congenitally Corrected Transposition of the Great Arteries......Page 1087
22.3.10 Complete Transposition of the Great Arteries and Intraatrial Baffle......Page 1088
22.3.11 Single Ventricle Physiology with Fontan Surgery......Page 1090
22.3.13 Coronary Anomalies......Page 1091
References......Page 1093
23 Cellular Electrophysiological and Genetic Mechanisms of Cardiac Arrhythmias......Page 1102
23.2.1.1 Normal Automaticity......Page 1103
23.2.1.2 Abnormal Automaticity......Page 1110
23.2.1.3 Some Clinical Characteristics of Arrhythmias Caused by Automaticity......Page 1112
23.2.2.1 Early Afterdepolarizations......Page 1113
23.2.2.2 Delayed Afterdepolarizations......Page 1117
23.3 Abnormalities of Repolarization and Their Genetic Determinants......Page 1121
23.4 Alterations in Refractory Period......Page 1123
23.5 Abnormal Impulse Conduction and Reentry......Page 1124
23.5.1 Mechanisms for Slow Conduction......Page 1127
23.5.2 Unidirectional Block of Impulse Conduction......Page 1131
23.5.3.1 Anatomical Pathways......Page 1135
23.5.3.2 Functional Pathways......Page 1137
23.5.3.3 Clinical Characteristics of Reentrant Excitation......Page 1141
23.6 Simultaneous Abnormalities of Impulse Initiation and Conduction......Page 1143
23.7 Conclusion......Page 1144
References......Page 1145
24 Clinical Cardiac Electrophysiology......Page 1152
24.2 History of Clinical Electrophysiology......Page 1153
24.3.2 The Electrophysiology Study......Page 1154
24.3.2.1 His-Bundle Recording......Page 1155
24.3.2.2 Intracardiac Chamber Recording......Page 1156
24.3.3.1 Baseline AV Conduction Intervals......Page 1157
24.3.3.2 Refractory Period Assessment......Page 1159
24.3.3.3 Induction, Definition of Mechanism, and Termination of Tachyarrhythmias......Page 1164
24.3.4 Safety of Electrophysiological Testing......Page 1165
24.5 Indications for Electrophysiology Studies......Page 1166
24.5.1.2 Tachycardia......Page 1167
24.5.2.1 Catheter Ablation......Page 1171
24.5.2.2 Guidance of Therapy......Page 1173
24.5.3.2 Ventricular Arrhythmias......Page 1174
References......Page 1175
25 Intracardiac Mapping......Page 1182
25.1.4 Contact Catheters......Page 1184
25.2 Recording Systems......Page 1185
25.4.1 Activation Sequence Mapping......Page 1186
25.4.3 Entrainment Mapping......Page 1187
25.5 Alternative Mapping Technologies......Page 1188
25.5.4 Global Data Acquisition from a Single Cardiac Cycle......Page 1189
25.6 Noncontact Mapping......Page 1190
25.7.1 Mapping of Atrioventricular Nodal Reentrant Tachycardia (AVNRT)......Page 1191
25.7.2.1 Mapping......Page 1194
25.7.3.1 Mapping to Guide Radiofrequency Ablation......Page 1196
25.7.3.2 Atypical Atrial Flutter......Page 1197
25.7.4 Focal Atrial Tachycardias......Page 1198
25.7.6 Conventional Diagnostic Electrophysiology Study for Ventricular Tachycardia and VentricularStimulation Studies......Page 1199
25.7.7 Mapping of Ventricular Tachycardia......Page 1200
25.7.7.2 Bundle Branch Reentrant VT......Page 1201
25.7.8 Conventional Mapping of Infarct-Related VT......Page 1202
25.7.8.3 Entrainment Mapping of VT......Page 1203
25.7.9 VT Ablation Using Complex Mapping Systems......Page 1204
25.7.10.1 Electroanatomic Mapping......Page 1205
References......Page 1206
26 Sinus and Atrial Arrhythmias......Page 1212
26.2.1 Electrophysiology of the Sinus Node......Page 1214
26.2.3 Autonomic Control of Sinus Rate......Page 1215
26.2.7 Sinus Arrhythmia......Page 1216
26.3 Sinus Node Dysfunction......Page 1217
26.3.1 Sick Sinus Syndrome......Page 1218
26.3.3 Sinoatrial Block......Page 1219
26.3.4 Diagnosis of Sinus Node Dysfunction......Page 1220
26.3.5.1 Sinus Node Recovery Time......Page 1221
26.3.5.4 Direct Sinus Node Recording......Page 1222
26.4 Atrial Arrhythmias......Page 1223
26.4.2 General Electrocardiographic Features of Atrial Arrhythmias......Page 1224
26.5.1 Overview......Page 1225
26.5.2 Electrocardiographic Features......Page 1227
26.6.3 P Wave Morphology......Page 1228
26.6.4 Localizing Tachycardia Focus to the Left or Right Atrium......Page 1229
26.6.5.1 Crista Terminalis......Page 1230
26.6.6.1 Pulmonary Veins......Page 1231
26.7.1 Overview......Page 1232
26.8.1 Overview......Page 1233
26.8.2.1 Electrocardiographic Features of Typical (CTI-Dependent) Flutter......Page 1234
26.8.2.2 Electrocardiographic Features of Atypical (Non-CTI-Dependent) Flutter......Page 1236
26.9.2.2 Tissue Substrate for Sustained AF......Page 1237
26.9.3 Epidemiology of AF......Page 1238
26.9.4 Electrocardiographic Features of Atrial Fibrillation......Page 1239
27 Clinical Electrophysiological Mechanisms of Tachycardias Arising from the Atrioventricular Junction......Page 1250
27.2.2 Conventional Concepts......Page 1251
27.2.3 Recent Developments......Page 1252
27.2.4 Proposed Models of the AVNRT Circuit......Page 1257
27.3 The Electrocardiogram......Page 1258
27.4.1 Antegrade and Retrograde AV Conduction Curves......Page 1260
27.4.2 Initiation of Tachycardia......Page 1262
27.4.2.2 Fast-Slow AVNRT......Page 1263
27.4.3 Effect of Stimulation During Tachycardia......Page 1264
27.6.1 Narrow-QRS Tachycardia......Page 1265
27.6.1.2 AVNRT versus AVRT due to Accessory Pathways......Page 1266
27.6.2.1 AVNRT with a bystanding Accessory Pathway versus Antidromic AVRT......Page 1269
27.8 Focal Junctional Tachycardia......Page 1270
References......Page 1271
28 Atrioventricular Dissociation......Page 1278
28.1.2 Types......Page 1280
28.2 History of Atrioventricular Block......Page 1282
28.3.2.1 Mobitz Type I (Wenckebach) Block......Page 1283
28.4 Methodology for Determining the Site of a Block......Page 1284
28.4.1.3 Conducted Beats: Narrow QRS Complexes......Page 1286
28.4.1.5 Escape Rhythm......Page 1287
Ajmaline......Page 1288
Atrial pacing......Page 1291
The His-bundle ECG......Page 1292
28.5.1 First-Degree AV Conduction Delay......Page 1293
28.5.2.1 Mobitz Type I (Wenckebach) Block......Page 1294
28.5.2.2 Mobitz Type II Block......Page 1296
28.6 Complete Block (Third-Degree AV Block)......Page 1297
28.7.4 Vagal Influences......Page 1298
28.7.8 Cardiomyopathy......Page 1299
28.9 Clinical Features......Page 1300
28.10.3 Second-Degree AV Block......Page 1301
28.11 Prognosis......Page 1302
29 Ventricular Tachycardia......Page 1310
29.1.2 Increased automaticity......Page 1312
29.1.3 Triggered activity......Page 1313
29.1.4 Re-entry......Page 1314
29.1.5 Criteria for Discriminating Between Cellular Electrophysiologicaland Clinical Mechanisms of Tachycardia......Page 1315
29.2.1.1 Relationship to the P wave......Page 1316
29.2.1.3 Chronology......Page 1317
29.2.3 Management......Page 1320
29.2.4 VES in normal subjects with apparently healthy hearts......Page 1321
29.2.5.1 Acute phase of myocardial infarction (Lown's classification)......Page 1323
29.2.5.2 The chronic phase......Page 1324
29.2.7 Other cardiac diseases......Page 1326
29.2.7.1 VES and cardiomyopathies......Page 1327
29.2.7.3 Aortic valve disease......Page 1328
29.3.1.1 Electrocardiographic features......Page 1329
29.3.1.2 Electrocardiographic discrimination between VT and SVT......Page 1331
29.3.2 Etiologies......Page 1333
29.3.2.1 Coronary artery disease......Page 1334
29.3.2.2 Dilated cardiomyopathy......Page 1335
29.3.2.4 Mitral valve prolapse......Page 1336
29.3.2.7 Brugada syndrome......Page 1337
29.3.2.8 Idiopathic VT......Page 1338
29.3.2.10 Catecholamine-induced polymorphic VT......Page 1339
29.3.2.13 Bouveret VT......Page 1340
29.3.3.3 Prevention of recurrence......Page 1341
29.3.3.4 Strategy for the use of palliative methods for the treatment of chronic recurrent VT......Page 1345
29.3.3.5 Radical treatment......Page 1346
References......Page 1348
30 Atrial Tachycardias in Infants, Children, and Young Adults with Congenital Heart Disease......Page 1356
30.1.1 Automatic/Triggered Atrial Tachycardias......Page 1357
30.1.2 Reentrant Atrial Tachycardias......Page 1361
30.1.3 Atrial Anatomy: Lessons from Atrial Flutter in Animal Models and Adult Patients withHeart Disease......Page 1362
30.1.4 Intra-Atrial Reentry in the Postoperative Patient with Congenital Heart Disease......Page 1364
30.2 Epidemiology......Page 1365
30.4 Treatment of Atrial Tachycardia......Page 1366
30.4.1 Mechanisms of Postoperative Atrial Reentrant Tachycardias......Page 1367
30.4.2 Intra-Atrial Tachycardias Associated with a Simple Atriotomy......Page 1368
30.4.3.1 Patients after Atrial Switch Operation......Page 1369
30.4.4 ``Figure-of-8'' Intra-Atrial Tachycardias......Page 1370
30.5 Long-Term Follow-Up of Patients with Atrial Tachycardia......Page 1372
References......Page 1373
31 Body Surface Potential Mapping Techniques......Page 1380
31.2 Recording Techniques......Page 1381
31.2.3 Computer Processing and Display......Page 1382
31.3 Lead Systems for Recording and Estimating Body Surface Potential Maps......Page 1383
31.3.3 Estimation......Page 1385
31.4.1 Qualitative Analysis......Page 1386
31.4.2 Quantitative Analyses of Body Surface Maps......Page 1387
31.4.3 Distributions of ECG Integrals (Areas)......Page 1389
31.5 Statistical Representation of Body Surface Maps......Page 1390
31.6 Summary......Page 1391
References......Page 1392
32 Body Surface Potential Mapping......Page 1394
32.2 History......Page 1395
32.3.2 Integral Maps......Page 1396
32.3.3 Principal Component Analysis......Page 1398
32.4.1 Atrial Excitation and Recovery......Page 1399
32.4.2 Ventricular Activation......Page 1402
32.4.3 Ventricular Repolarization......Page 1405
32.5.1.1 Myocardial Infarction......Page 1406
32.5.1.3 Myocardial Ischemia......Page 1410
32.5.2 Right Ventricular Hypertrophy......Page 1412
32.5.3 Left Ventricular Hypertrophy......Page 1413
32.5.4 Right Bundle Branch Block......Page 1414
32.5.5 Left Bundle Branch Block......Page 1415
32.5.6 Left Anterior Fascicular Block......Page 1417
32.5.7 Wolff–Parkinson–White Syndrome......Page 1418
32.5.8.1 Postinfarction Ventricular Tachycardias: Identification of Site of Originof Ventricular Tachycardias......Page 1423
32.5.8.4 Long QT Syndrome......Page 1424
32.6 Conclusions......Page 1426
References......Page 1428
33 Ambulatory Electrocardiogram Monitoring......Page 1436
33.1 Introduction......Page 1439
33.2.1 Electrodes and Electrode Preparations......Page 1440
33.2.2.1 Leads for Recording Arrhythmias......Page 1441
33.2.4 Esophageal and Intracardiac Leads......Page 1443
33.2.5.1 Tape Recorders......Page 1444
33.2.5.3 Storage Media......Page 1445
33.3.1 Battery Failure......Page 1446
33.3.3 Failure of Electrodes, Lead Wires, or Patient Cable......Page 1447
33.4.1 Analog Holter Tape Recording......Page 1449
33.5 Methods of Analysis......Page 1451
33.5.3.1 From Tape Recorders......Page 1452
33.5.3.2 From Solid-State Recorders......Page 1453
33.5.4.1 Technical Aspects – Analysis of Ischemic Episodes......Page 1455
33.5.4.2 Beat-to-Beat Analysis......Page 1456
33.5.5 Analysis of HRV......Page 1457
33.5.5.2 Geometric Measures for HRV Analysis......Page 1458
33.5.5.3 Frequency-Domain Analysis of HRV......Page 1459
33.5.6.2 Parameters of Heart-Rate Turbulence......Page 1461
33.5.7.2 Technical Aspects......Page 1462
33.5.8.3 Pitfalls and Limitations......Page 1463
33.5.9.2 Pitfalls and Limitations......Page 1464
33.5.10 Reports......Page 1465
33.6 Incidence of Arrhythmias in Apparently Healthy Individuals......Page 1466
33.6.1 Maximal and Minimal Heart Rate......Page 1467
33.6.3 AV Block......Page 1468
33.7 ST-Segment Changes in Apparently Healthy Persons......Page 1469
33.8.1.1 Palpitations......Page 1470
33.8.1.3 Previous Ischemic Strokes......Page 1471
33.8.2.1 Sinoatrial Disorders......Page 1472
33.8.2.2 AV Block and Intraventricular Disorders......Page 1473
33.8.2.3 Paroxysmal Atrial Arrhythmias......Page 1474
33.8.2.4 Paroxysmal Junctional Reciprocating Tachycardias......Page 1475
33.8.2.5 Ventricular Arrhythmias......Page 1476
33.8.3.1 General Considerations......Page 1478
33.8.3.2 Silent Myocardial Ischemia (SI)......Page 1479
33.8.3.4 Limitations of Holter Monitoring for Myocardial Ischemia......Page 1480
Prevalence of Ventricular Arrhythmias......Page 1482
Prognostic Significance of VLP......Page 1483
Stepwise Risk Stratification......Page 1485
Prognostic Significance of HRV......Page 1487
Prognostic Significance of Heart-Rate Turbulence......Page 1489
33.8.4.5 Systemic Hypertension (SH)......Page 1490
33.8.5.1 Pacemaker and ICD Function......Page 1491
33.8.5.2 Antiarrhythmic Drugs (AADs)......Page 1493
33.9.1 Evaluation of Symptoms......Page 1495
33.9.2 Evaluation of Patients with Known Cardiovascular Disease......Page 1496
33.10 Future Perspectives of Ambulatory Monitoring......Page 1497
References......Page 1498
34 The Pre-Hospital Electrocardiogram......Page 1506
34.1.2 Ideological Background......Page 1508
34.2 Detection of ECG Abnormalities......Page 1509
34.2.2 Arrhythmias......Page 1511
34.3.3 Direct Transport to Remote Hospital......Page 1512
34.4.4 Earlier Start of Anti-Ischemic Therapy......Page 1513
34.6.1 Increase in Delay......Page 1514
34.7.3 Practical Implementation......Page 1515
34.8.1.2 With Computer Assistance......Page 1516
34.9.3 Elsewhere......Page 1517
34.10.4 Other Changes......Page 1518
34.11.5 Advantages of Continuous Prehospital ECG Monitoring......Page 1519
34.12.1 Medtronic Lifepak......Page 1520
34.13 Various Types of Arrhythmia......Page 1521
34.13.2.1 Ventricular Fibrillation......Page 1522
34.14.2 Pulseless Electrical Activity......Page 1523
34.15.2 Important Prehospital ECG Research Projects......Page 1524
References......Page 1525
35 Heart Rate Variability......Page 1532
35.2 Definitions, Synonyms, Abbreviations......Page 1535
35.3.1.1 Statistical Methods......Page 1540
35.3.1.2 Geometric Methods......Page 1541
35.3.1.3 Return Map Evaluation......Page 1543
35.3.1.5 Time-Domain Analysis of the HR-HRV Relationship......Page 1548
35.3.2 Frequency-Domain Analysis......Page 1550
35.3.2.1 Nonparametric Spectral Analysis......Page 1552
35.3.2.2 Parametric Spectral Analysis......Page 1554
Short-Time Fourier Transform......Page 1555
Wavelet Analysis......Page 1556
Huang-Hilbert Transform......Page 1557
35.3.4 Nonlinear/Chaos-Derived Methods......Page 1558
Power-Law Behavior (1/f Fluctuation)......Page 1559
Rescaled Range (R/S)......Page 1560
Detrended Fluctuation Analysis......Page 1561
Correlation Dimension......Page 1563
35.3.4.2 Entropy Analysis......Page 1564
Approximate Entropy (ApEn)......Page 1565
Symbolic Dynamics......Page 1566
Information Entropy......Page 1568
35.3.4.3 Methods for Chaos and Determinism Analysis......Page 1569
Largest Lyapunov Exponent......Page 1570
Correlation Coefficients......Page 1571
35.3.4.6 Phase-Rectified Signal Averaging Method......Page 1572
35.3.5.1 Time-Domain Method......Page 1573
35.3.5.2 Cross-Spectrum......Page 1575
35.3.5.4 Baroreflex Sensitivity......Page 1577
Noninvasive Approach (Internal Stimuli)......Page 1578
35.3.5.5 Heart Rate Turbulence......Page 1579
35.4.1 Ideal HRV Method and Index......Page 1580
35.4.2.2 Errors Relating to Digitization Rate......Page 1581
35.4.2.4 Errors Related to the QRS-Wave Detectors......Page 1585
35.4.2.6 Non-Stationarity as a Source of Errors......Page 1586
35.4.3 Data Length......Page 1587
35.4.5 Universality of HRV Analysis......Page 1588
35.4.7 Biological Variations......Page 1593
35.4.7.2 Inter-Individual Variation......Page 1594
35.4.7.4 Reproducibility......Page 1596
35.4.7.5 Reclassification Rate......Page 1608
35.4.8 Selection of Method for HRV Analysis......Page 1609
35.4.8.1 Reliability......Page 1611
35.4.8.2 Explicitness......Page 1616
35.4.8.3 Redundancy and Inter-Changeability Among Different Methods and Measures......Page 1617
35.4.9 Normal Limits and Abnormal HRV......Page 1619
35.4.10 Physicians' Compliance with HRV Measures......Page 1625
35.5 Physiological Basis of Heart Rate Fluctuations......Page 1628
35.5.2.1 Pacemaker Cells......Page 1630
35.5.3.1 Acethylcholine......Page 1631
35.5.3.4 Nitric Oxide......Page 1633
35.5.5 Mechanical-Electrical Feedback......Page 1634
35.5.7.2 Hypothalamic–Pituitary–Adrenal System......Page 1635
35.5.7.4 Gonadal Hormones......Page 1636
Efferent Limb of Cardiac Vagal Control......Page 1637
Afferent Limb of Cardiac Autonomic Control......Page 1638
35.5.9.3 Accentuated Antagonism......Page 1639
35.5.10.3 Oculocardiac Reflex......Page 1640
35.6.1 Genetic Factors......Page 1641
35.6.2.1 Age......Page 1642
35.6.2.2 Cardiac Autonomic Control Changes Related to Aging......Page 1643
HRV Changes Related to Aging......Page 1644
35.6.2.3 Gender......Page 1647
35.6.2.5 Body Mass......Page 1653
Intrinsic Heart Rate......Page 1655
Actual Heart Rate (Resting)......Page 1657
35.6.2.7 Respiration......Page 1660
35.6.3.1 Physical Activity......Page 1662
35.6.3.2 Mental Stress......Page 1663
35.6.3.3 Smoking......Page 1664
References......Page 1665
36 Exercise Electrocardiography and Exercise Testing......Page 1696
36.2 Safety of Exercise Testing, Precautions, and Contraindications......Page 1698
36.3 Exercise Protocols......Page 1699
36.4 Exercise Endpoints......Page 1702
36.5.1 Recording of the Electrocardiogram......Page 1703
36.5.2 Computer Processing of the Electrocardiogram......Page 1704
36.6.1 Changes of the ECG During Exercise in Normal Subjects......Page 1706
36.6.2.1 ST Segment Depression......Page 1707
Horizontal and Downsloping ST Segment Depression......Page 1708
Magnitude of ST Segment Depression and Probability of Coronary Artery Disease......Page 1709
Magnitude of ST Segment Depression and the Degree of Anatomical Coronary Artery Disease......Page 1711
Time Course of ST Segment Depression......Page 1713
ST Segment Depression and/or Exercise-Induced Angina......Page 1714
36.6.2.2 ST Segment Elevation......Page 1715
R-Wave Amplitude......Page 1716
QRS-Duration......Page 1717
36.7 Exercise Testing to Diagnose Coronary Artery Disease......Page 1718
36.7.1 Pretest Probability......Page 1719
36.7.2 Diagnostic Characteristics and Test Performance......Page 1720
36.7.3 Probability Analysis......Page 1721
36.7.5 Electrocardiographic Factors Influencing Sensitivity and Specificity......Page 1722
36.8 Exercise Testing in Patients with Coronary Artery Disease......Page 1723
36.8.1 Risk Stratification and Assessment of Prognosis with Exercise Testing......Page 1724
36.9.1 Exercise Testing in Patient Management......Page 1725
36.10.1 Exercise Testing after Coronary Artery Bypass Grafting......Page 1726
36.11.2 Supraventricular Arrhythmias......Page 1727
36.11.3.1 Exercise-Induced Sustained Ventricular Tachycardia......Page 1728
36.12.2 Aortic Valve Stenosis and Regurgitation......Page 1729
References......Page 1730
37 Computer Analysis of the Electrocardiogram......Page 1740
37.1 Some History......Page 1742
37.2.2 ECG Management Systems......Page 1743
37.3 Information Content of Lead Systems; Lead Transformations......Page 1744
37.4 Computer Processing of the ECG......Page 1745
37.5 Reference Databases for Program Evaluation......Page 1746
37.6 Data Acquisition......Page 1748
37.7.1 Power-Line Interference......Page 1749
37.7.2 Baseline Wander......Page 1751
37.7.3 Muscle Noise......Page 1753
37.7.4 Spikes......Page 1754
37.8 Detection of QRS Complexes......Page 1755
37.9 Detection of P Waves......Page 1756
37.10 QRS Typing......Page 1757
37.11 Forming a Representative Complex......Page 1759
37.12 Waveform Recognition......Page 1760
37.13 Parameter Computation......Page 1763
37.14.2 Deterministic ECG Computer Programs......Page 1764
37.14.3 Statistical ECG Computer Programs......Page 1765
37.14.4 Methodology of ECG Computer Program Evaluation......Page 1766
37.14.6 Comparison of Computer Results with Clinical ``Truth''......Page 1768
37.14.7 Computer-Aided Physician's Interpretation of the ECG......Page 1771
37.15 Rhythm Analysis Programs......Page 1772
37.16 Serial Comparison Programs......Page 1773
37.17 Computer Analysis of Pediatric Electrocardiograms......Page 1774
37.18 Conclusion......Page 1775
References......Page 1776
38 Pacemaker Electrocardiography......Page 1786
38.3 Relationship Between the Stimulation Impulse and Cardiac Activity......Page 1787
38.4 The ECG Appearance of Different Pacing Modes......Page 1788
38.5 Dual-Chamber Pacing......Page 1790
38.6 Diagnostic Tools......Page 1796
38.7 Pacemaker Malfunction and Pseudomalfunction......Page 1798
38.8 Functional Tests......Page 1805
38.9 Biventricular Pacing, Cardiac Resynchronization......Page 1808
38.10 Tachycardia and ICD......Page 1810
References......Page 1811
39 The Signal-Averaged Electrocardiogram......Page 1812
39.2 Methods of Signal Averaging......Page 1813
39.3.2 Filtering and Time Domain Parameters......Page 1814
39.3.3 Physiological Background......Page 1817
39.4.1 Recent Myocardial Infarction......Page 1818
39.4.5 Success of Arrhythmia Surgery......Page 1819
39.4.6 Efficacy of Anti-Arrhythmic Drugs......Page 1820
39.4.7 Cardiac Transplant......Page 1821
39.5 Late Potentials and Frequency Analysis......Page 1822
39.6 Late Potentials and Frequency Analysis in Clinical Applications......Page 1823
39.7.1 Spectrotemporal Mapping......Page 1826
39.7.2 Spectral Turbulence Analysis......Page 1828
39.8.1 Introduction......Page 1829
39.8.2 Signal Recording and Analysis......Page 1830
39.9.1 Ischemic Heart Disease......Page 1831
39.9.2 Acute Myocardial Ischemia......Page 1832
39.9.4 Stress-Induced Ischemia......Page 1833
39.9.6 Conduction Abnormalities......Page 1834
References......Page 1835
40 Electrocardiography in Epidemiology......Page 1842
40.1.1 ECG Coding Schemes from Historical Perspective......Page 1844
40.1.2.2 Definition of Codable Waves......Page 1845
40.1.2.3 Coding Criteria for Serial ECG Changes......Page 1846
40.2.1 Contrasting Prevalence and Age Trends of ECG Abnormalitiesin Middle-Aged Men and Women......Page 1847
40.2.2 Prevalence of ECG Abnormalities in Adult Male Populations......Page 1850
40.2.3 Prevalence of ECG Abnormalities in Ostensibly CHD-Free US Male Populations......Page 1851
40.3.1 ECG Abnormalities and Mortality Risk in General Male Populations......Page 1852
40.3.2.1 Major Abnormalities......Page 1853
40.3.3 Comparative Value of the ECG in Prediction of CHD Risk in Men and Women......Page 1854
40.3.4 Contrasting Prognostic Significance of ECG Abnormalities in Symptomatic and Asymptomatic Men......Page 1855
40.3.5 Contrasting Racial Differences in Prognostic Significance of ECG Abnormalities......Page 1856
40.4.1 Mortality Risk in Q Wave Myocardial Infarction......Page 1857
40.4.3.2 Framingham Study......Page 1860
40.4.3.4 Other Studies Comparing Recognized Versus Unrecognized MI......Page 1863
40.4.5 Heart Attack Prevention Programs and Prognostic Value of Rest and Exercise ECG Abnormalities......Page 1864
40.4.6 Time Trends: Are Risk Evaluation Data from Older Studies Still Valid?......Page 1865
40.5.2 Time Trends in ECG-LVH Prevalence......Page 1866
40.5.4 LVH and Overweight......Page 1867
40.5.5 ECG-LVH Prevalence in Hypertensive Cohorts......Page 1868
40.5.7 Prognostic Value of ECG-LVH in General Populations......Page 1870
40.5.8 Incident ECG-LVH......Page 1872
40.7.1 New Reports on Repolarization Abnormalities as Mortality Predictors from LargePopulation-Based Cohorts......Page 1874
References......Page 1875
41 The Dog Electrocardiogram: A Critical Review......Page 1880
41.1.2 Beagle Electrocardiogram......Page 1882
41.2.1 Lead Systems......Page 1884
41.2.2 Position and Restraint......Page 1886
41.2.3 Electrodes......Page 1889
41.2.5 Artifacts......Page 1890
41.3.1.2 Intervals......Page 1892
41.3.2.1 Wandering Pacemaker......Page 1893
41.3.3 QRS Complex......Page 1896
41.3.6 Evolution During the First 3 Months of Life......Page 1897
41.3.8.1 Normal Criteria......Page 1899
41.3.9.1 QRS Complex......Page 1900
41.4.2 Respiratory Sinus Arrhythmia......Page 1902
41.5.1 Normal Values......Page 1903
41.5.5 Evolution During the First 3 Months of Life......Page 1905
41.6 ECG Descriptors and Pattern Code......Page 1906
41.6.1 Descriptors Applicable to All Leads......Page 1907
41.7 Electrocardiographic Abnormalities: Diagnostic Criteria......Page 1908
41.7.1.1 Right Ventricular Hypertrophy......Page 1909
41.7.1.2 Left Ventricular Hypertrophy......Page 1910
41.7.3 Bypass Conduction......Page 1911
41.8.1.1 Sinus Rhythms......Page 1912
41.8.1.3 Atrioventricular Junctional (Nodal) Rhythms......Page 1914
41.8.2.3 Ventricular Parasystole......Page 1915
41.8.2.4 Ventricular Tachycardia......Page 1916
41.8.2.5 Atrioventricular Dissociation......Page 1917
41.8.3.2 Atrioventricular Block......Page 1918
41.9 Comparing Serial Electrocardiogram Records......Page 1919
41.10.1 Drug Effects on Transmembrane Action Potentials and ECG Changes......Page 1920
41.10.1.2 The QT Interval......Page 1921
Acknowledgement......Page 1922
References......Page 1923
42 The Mammalian Electrocardiogram: Comparative Features......Page 1928
42.2 Literature Reviews......Page 1930
42.3.2 QT Duration and ST Segment......Page 1931
42.3.3 Ventricular Activation Patterns......Page 1933
42.3.5 Effect of ECG Characteristics on Choice of Lead Systems and Terminology......Page 1934
42.4.2.2 Chemical Restraint......Page 1935
42.4.4.2 Chest Leads......Page 1936
42.4.4.4 Cardiac Electric Fields and Generation of Cardiac Potentials in Hoofed Mammals......Page 1938
42.4.4.6 Fetal Electrocardiography......Page 1939
42.4.6 Telemetry and Holter Monitoring......Page 1940
42.5.2 Heart Rate Variability and Acceleration......Page 1941
42.5.4 Heart-Rate Dependence of Electrocardiographic Time Intervals PR, QRS, and QT......Page 1942
42.6.1 Primates......Page 1943
42.6.2 Perissodactyla......Page 1947
42.6.3 Artiodactyla......Page 1948
42.6.5 Marsupialia......Page 1950
42.6.7 Rodentia......Page 1954
42.6.8 Carnivora......Page 1959
References......Page 1960
43 12 Lead Vectorcardiography......Page 1968
43.1.3 Spatial Vector......Page 1970
43.1.4.1 Theoretical Considerations......Page 1972
43.1.4.3 Corrected Orthogonal Lead Systems......Page 1973
43.1.5.2 Spatial Vector Loop......Page 1974
43.1.6.2 Display Techniques......Page 1975
43.2.1 Introduction......Page 1978
43.2.2.1 Techniques......Page 1979
43.2.2.3 Population Data......Page 1980
43.2.2.4 Methods of Analysis......Page 1981
43.2.2.5 Statistical Considerations......Page 1982
43.2.3.1 Wave Amplitudes and Durations......Page 1983
43.2.3.3 Comparative Vectorcardiography......Page 1984
43.2.4.2 QRS Loops......Page 1985
43.2.4.3 Left Axis Deviation......Page 1986
43.3.1.2 Effects of Age, Sex and Race......Page 1988
43.3.2.1 Right Atrial Enlargement......Page 1989
43.3.2.2 Left Atrial Enlargement......Page 1990
43.3.3.1 Diagnostic Criteria......Page 1991
43.3.4.2 RVH: Type B......Page 1996
43.3.4.3 RVH: Type C......Page 1997
43.3.4.4 RVH: Type D......Page 1998
43.3.6 Pediatric Vectorcardiography......Page 1999
43.4.1.2 Anatomical Definitions......Page 2000
43.4.2.3 Inferior Myocardial Infarction......Page 2001
43.4.2.4 Inferior Myocardial Infarction Versus Left Anterior Fascicular Block......Page 2003
43.4.2.5 Posterior Myocardial Infarction......Page 2004
43.4.2.7 Anterolateral Myocardial Infarction......Page 2007
43.4.2.8 Bites......Page 2009
43.5.1 Introduction......Page 2010
43.5.1.1 Conduction System......Page 2011
43.5.2.1 Left Bundle Branch Block......Page 2012
43.5.2.4 Incomplete Right Bundle Branch Block......Page 2013
43.5.3 Fascicular Block......Page 2015
43.5.3.1 Left Anterior Fascicular Block......Page 2016
43.5.3.2 Left Posterior Fascicular Block......Page 2020
43.5.4 Bifascicular Block......Page 2021
43.5.5 Wolff–Parkinson–White Pattern......Page 2022
43.5.6 Intraventricular Conduction Defects......Page 2023
References......Page 2024
44 Magnetocardiography......Page 2026
44.2.2 Forward Problem......Page 2028
44.3.2 General......Page 2029
44.3.5 Different Systems: Sensors......Page 2030
44.3.7 Different Systems: Need for Standardization......Page 2031
44.4.1.5 Independent Component Analysis......Page 2032
44.5.3 Visualizations......Page 2033
44.6 Localization of Preexcitation and Cardiac Arrhythmias by Magnetocardiographic Mapping......Page 2034
44.7 Fetal Magnetocardiography......Page 2035
44.8 Arrhythmia Risk Assessment......Page 2036
44.8.1.1 Magnetocardiographic P-Wave in Patients with AF, Analyses of Non-Filter Signal and Applicationof High-Pass Filtering Techniques......Page 2038
44.8.1.2 Spatial MCG Maps, Field Polarity, and Orientation during Atrial Activation and Applicationof Surface Gradient Methods......Page 2039
44.9 Myocardial Ischemia and viability......Page 2041
44.10 Discussion......Page 2043
References......Page 2044
45 Polarcardiography......Page 2048
45.2 Spherical Coordinates Applied to the Body......Page 2049
45.3 Spatial Magnitude......Page 2050
45.3.1 Baseline Clamping......Page 2054
45.3.2.1 P Waves......Page 2058
45.3.2.2 QRS Complex......Page 2059
45.3.2.4 T Wave......Page 2060
45.4 Angle Tracings......Page 2061
45.4.1 Latitudes and Longitudes......Page 2063
45.4.2 Normal Directions of Representative Heart Vectors......Page 2065
45.4.3 Spherocardiogram......Page 2067
45.5.1.1 Criteria Relating to the QRS Complex......Page 2068
45.5.2 Evaluation of Performance of Infarction Criteria......Page 2070
45.5.3 Criteria for Left Bundle Branch Block......Page 2071
45.5.4 Left Anterior Fascicular Block......Page 2072
45.5.5 Left Ventricular Hypertrophy......Page 2073
45.6 Conclusion......Page 2074
References......Page 2075
Appendix 1: Adult Normal Limits......Page 2076
A1.1 Normal Limits of the 12-Lead ECG in White Caucasians......Page 2077
A1.3 Normal Limits of the 12-Lead ECG in Japanese......Page 2103
A1.4 Normal Limits of Right-Sided Chest Leads in Caucasians......Page 2116
A1.5.1 Normal Limits in Males......Page 2118
A1.5.2 Normal Limits in Females......Page 2125
A1.5.3 Effect of Age, Build and Race on the Orthogonal-Lead ECG......Page 2126
A1.6 Normal Limits of Polarcardiographic Data......Page 2129
A1.7.2 Linear Statistics......Page 2138
A1.7.3 Directional Statistics......Page 2141
References......Page 2144
Appendix 2: Paediatric Normal Limits......Page 2146
A2.1 Normal Limits of the Paediatric 12-Lead ECG......Page 2147
A2.2 Percentile Charts......Page 2179
A2.3 Additional 12-Lead Pediatric ECG Normal Limits......Page 2199
A2.4 Normal Limits of the Pediatric Orthogonal-Lead ECG......Page 2201
References......Page 2214
Appendix 3: Instrumentation Standards and Recommendations......Page 2216
A3.2 General Design Considerations......Page 2217
A3.2.2 Guidance for Diagnostic ECG......Page 2218
A3.2.4 Typical Performance Requirements for Cardiac Monitors......Page 2219
A3.3 Patient Safety Standards......Page 2220
A3.5.1 Heart Rate Variability......Page 2221
References......Page 2222
Appendix 4: Coding Schemes......Page 2226
A4.1.1.1 Q and QS Patterns......Page 2227
A4.1.1.3 High-Amplitude R Waves......Page 2228
A4.1.1.4 ST Junction (J) and Segment Depression......Page 2229
A4.1.1.6 AV Conduction Defect in Codes......Page 2230
A4.1.1.8 Arrhythmias......Page 2231
A4.1.1.9 ST-Segment Elevation......Page 2232
A4.1.1.12 ECG Criteria for Significant Serial ECG Change......Page 2233
A4.2 The Punsar Code......Page 2236
Appendix 5: Normal Limits of the 12 Lead Vectorcardiogram......Page 2238
B5.1 Scalar Measurements from the Leads X, Y and Z......Page 2239
A5.1.2 Q Wave Amplitude and Duration......Page 2240
A5.1.3 R Wave Amplitude and Duration......Page 2242
A5.1.4 S Wave Amplitude and Duration......Page 2243
A5.1.5 T Wave Amplitude......Page 2244
A5.2.2 Magnitude of Maximal Spatial QRS Vector......Page 2245
A5.2.3 Magnitude of Maximal Planar QRS Vector......Page 2246
A5.2.5 Maximal T Vector Angle......Page 2247
Appendix 5B Normal Limits of Paediatric 12-Lead Vectorcardiogram......Page 2248
Index......Page 2252