The Complete Guide to ECGs, 3rd Edition

569 Pages·2008·4.27 MB·English

by  James O'Keefe

The Complete
Guide to ECGs
Third Edition
James H. O’Keefe, MD, FACC
Professor of Medicine
University of Missouri, Kansas City
Director, Preventive Cardiology
Mid America Heart Institute
St. Lukes Hospital
Kansas City, Missouri
Stephen C. Hammill, MD, FACC, FHRS
Past President, Heart Rhythm Society
Professor of Medicine
Director, Electrocardiography Laboratory
Mayo Clinic
Rochester, Minnesota
Mark S. Freed, MD, FACC
President and Editor-in-Chief
Physicians’ Press
Royal Oak, Michigan
Steven M. Pogwizd, MD, FACC
Featheringill Endowed Professor in Cardiac Arrhythmia Research
Professor of Medicine, Physiology & Biophysics, and Biomedical Engineering
Associate Director, Cardiac Rhythm Management Laboratory
The University of Alabama at Birmingham
Birmingham, Alabama
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6048
ISBN-13: 978-07637-6405-0
Printed in the United States of America
13 12 11 10 09 10 9 8 7 6 5 4 3 2
Dedication
To my family. My connection from the past, into the future. The foundation that brings
joy, meaning and strength to my life.
James O’Keefe
To my wife Karen and sons Noel, Eric, Steve, and Danny — thanks for your patience
and support.
Stephen Hammill
To my mother, father, Ralph, Susie, Bradley, Paulie, Jill, and Josephine, the joys of my
life.
Mark Freed
To my wife Cindy, and to my children Leah and Mike, with love; and in memory of my father,
Edward.
Steven Pogwizd
James O’Keefe, Jr., MD Stephen Hammill, MD Mark Freed, MD Steven Pogwizd, MD
Preface
The Complete Guide to ECGs has been developed as a unique and practical means for physicians,
physicians-in-training, and other medical professionals to improve their ECG interpretation skills. The
highly interactive format and comprehensive scope of information are also ideally suited for physicians
preparing for the American Board of Internal Medicine (ABIM) Cardiovascular Disease or Internal
Medicine Board Exams, the American College of Cardiology ECG proficiency test, and other exams
requiring ECG interpretation.
This Third Edition includes many new ECG cases and quizzes and contains more than 1000 questions
and answers related to ECG interpretation. Also featured are sections on approach to ECG interpretation
and ECG differential diagnosis and an expanded final section on ECG criteria.
We recommend using the answer sheet on many other ECGs in addition to the sample tracings provided.
Study groups and regular educational conferences are ideal settings for the presentation of unknown
ECGs and discussion of their correct interpretation.
We hope you enjoy reading The Complete Guide to ECGs and find it a practical resource for patient
care.
James O’Keefe, Jr., M.D.
Stephen Hammill, M.D.
Mark Freed, M.D.
Steven Pogwizd, M.D.
Table of Contents
General Instructions ............................................................... 1
Common Dilemmas in ECG Interpretation ............................................. 2
Approach to ECG Interpretation ..................................................... 5
Heart rate .......................... 5 QRS voltage ........................... 9
P wave ............................ 6 Precordial R wave progression ............ 9
Origin of the rhythm ................. 7 Q wave .............................. 10
PR interval ......................... 7 ST segment........................... 10
QRS width ......................... 8 T wave .............................. 11
QT interval ......................... 8 U wave .............................. 11
QRS axis .......................... 9 Pacemakers .......................... 11
ECG Differential Diagnosis ........................................................ 15
P wave ........................... 15 QRS morphology ...................... 18
PR interval ........................ 16 ST segment........................... 18
PR segment ....................... 16 T wave .............................. 19
QRS duration ...................... 16 QT interval ........................... 19
QRS amplitude .................... 17 U wave .............................. 19
QRS axis ......................... 17 PP pause ............................. 20
Q wave ........................... 17 Group beating......................... 20
R wave progression ................. 18
ECG Cases and Quizzes........................................................... 21
ECG Criteria (see next page for expanded table of contents) ............................. 525
Index of Cases ................................................................. 555
ECG Criteria (Section 4)
GENERAL FEATURES ABNORMALITIES OF QRS AXIS 66. ST and/or T wave abnormalities
01. Normal ECG ............. 525 36. Left axis deviation .......... 538 suggesting electrolyte
02. Borderline normal ECG or 37. Right axis deviation .........539 disturbances ...............546
normal variant ............ 525 38. Electrical alternans..........539 67. ST and/or T wave abnormalities
03. Incorrect electrode placement 526 secondary to hypertrophy.....546
04. Artifact .................. 526 QRS VOLTAGE ABNORMALITIES 68. Prolonged QT interval .......546
39. Low voltage ...............539 69. Prominent U waves .........547
P WAVE ABNORMALITIES 40. Left ventricular hypertrophy ..539
05. Right atrial abnormality ..... 527 41. Right ventricular hypertrophy .540 CLINICAL DISORDERS
06. Left atrial abnormality ...... 527 42. Combined ventricular 70. Digitalis effect .............547
hypertrophy ...............540 71. Digitalis toxicity............547
SUPRAVENTRICULAR RHYTHMS 72. Antiarrhythmic drug effect ....547
07. Sinus rhythm ............. 527 INTRAVENTRICULAR 73. Antiarrhythmic drug toxicity ..548
08. Sinus arrhythmia .......... 527 CONDUCTION ABNORMALITIES 74. Hyperkalemia ..............548
09. Sinus bradycardia.......... 528 43. RBBB, complete ...........541 75. Hypokalemia ..............548
10. Sinus tachycardia .......... 528 44. RBBB, incomplete ..........541 76. Hypercalcemia .............548
11. Sinus pause or arrest ....... 528 45. Left anterior fascicular block ..541 77. Hypocalcemia..............548
12. Sinoatrial exit block ........ 528 46. Left posterior fascicular block .542 78. Atrial septal defect, secundum .549
13. Atrial premature complexes .. 529 47. LBBB, complete............542 79. Atrial septal defect, primum...549
14. Atrial parasystole .......... 529 48. LBBB, incomplete ..........542 80. Dextrocardia, mirror image ...549
15. Atrial tachycardia .......... 530 49. Nonspecific intraventricular 81. Chronic lung disease ........549
16. Atrial tachycardia, multifocal. 530 conduction disturbance ......542 82. Acute cor pulmonale including
17. Supraventricular tachycardia, 50. Functional (rate-related) aberrant pulmonary embolus .........550
paroxysmal ............... 530 intraventricular conduction ...542 83. Pericardial effusion .........550
18. Atrial flutter .............. 531 84. Acute pericarditis ...........550
19. Atrial fibrillation .......... 531 Q-WAVE MYOCARDIAL 85. Hypertrophic cardiomyopathy .551
INFARCTIONS 86. Central nervous system disorder551
JUNCTIONAL RHYTHMS 51. Anterolateral (recent or acute) .544 87. Myxedema ................551
20. AV junctional premature 52. Anterolateral (indeterminate 88. Hypothermia ..............551
complexes ............... 532 or old) ...................544 89. Sick sinus syndrome.........552
21. AV junctional escape complexes 532 53. Anterior or anteroseptal (recent or
22. AV junctional rhythm acute) ....................544 PACED RHYTHMS
/tachycardia .............. 533 54. Anterior or anteroseptal 90. Atrial or coronary sinus pacing 552
(indeterminate or old) .......544 91. Ventricular demand pacemaker
VENTRICULARRHYTHMS 55. Lateral (recent or acute) ......544 (VVI), normally functioning ..552
23. Ventricular premature 56. Lateral (indeterminate or old) .544 92. Dual-chamber pacemaker (DDD)552
complexes ............... 533 57. Inferior (recent or acute) .....544 93. Pacemaker malfunction, not
24. Ventricular parasystole ..... 534 58. Inferior (indeterminate or old) .544 constantly capturing (atrium or
25. Ventricular tachycardia ..... 534 59. Posterior (recent or acute) ....544 ventricle) .................553
26. Accelerated idioventricular 60. Posterior (indeterminate or old) 544 94. Pacemaker malfunction, not
rhythm .................. 535 constantly sensing (atrium or
27. Ventricular escape complexes or REPOLARIZATION ventricle) .................553
rhythm .................. 535 ABNORMALITIES
28. Ventricular fibrillation ...... 535 61. Normal variant, early
repolarization ..............544
AV CONDUCTION 62. Normal variant, juvenile T
ABNORMALITIES waves ....................545
29. AV block, 1° ............. 535 63. Nonspecific ST and/or T wave
30. AV block, 2°-Mobitz type I abnormalities ..............545
(Wenckebach) ............ 536 64. ST and/or T wave abnormalities
31. AV block, 2°-Mobitz type II . 536 suggesting myocardial ischemia 545
32. AV block, 2:1............. 537 65. ST and/or T wave abnormalities
33. AV block, 3° ............. 537 suggesting myocardial injury ..546
34. Wolff-Parkinson-White pattern 537
35. AV dissociation ........... 538
Abbreviations
APC Atrial premature contraction RBBB Right bundle branch block
AV Atrioventricular RVH Right ventricular hypertrophy
COPD Chronic obstructive pulmonary disease SA Sinoatrial
JPC Junctional premature complex SVT Supraventricular tachycardia
LAFB Left anterior fascicular block VA Ventriculoatrial
LBBB Left bundle branch block VF Ventricular fibrillation
LPFB Left posterior fascicular block VPC Ventricular premature contraction
LVH Left ventricular hypertrophy VT Ventricular tachycardia
MI Myocardial infarction WPW Wolff-Parkinson-White
Nomenclature
The relative amplitudes of the component waves of the QRS complex are described using small (lower
case) and large (upper case) letters. For example, an rS complex describes a QRS with a small R wave
and a large S wave; a qRs complex describes a QRS with a small Q wave, a large R wave, and a small
S wave; and an RSR’ complex describes a QRS with a large R wave, a large S wave, and a large
secondary R wave (R’). When the QRS complex consists solely of a Q wave, a “QS” designation is
used.
Acknowledgments
We wish to acknowledge Monica Crowder Kaufman for her outstanding work in typing and
formatting this guide, Norm Lyle for cover art, and the excellent staff at Jones and Bartlett
Publishers. We are indebted to these individuals, and hope their efforts are well-received.
James O’Keefe, Jr., M.D.
Stephen Hammill, M.D.
Mark Freed, M.D.
Steven Pogwizd, M.D.
Notice
The ECG interpretations and criteria expressed in this book represent a consensus among the
authors based on previously published literature and their own experience and viewpoints. The
authors and publisher disclaim responsibility for adverse effects resulting from omissions or
undetected errors or adverse results obtained from the use of such information. Readers are
encouraged to review other references on ECG interpretation to further expand their knowlege
and interpretation skills.
General Instructions
Read each ECG in a thorough and systematic fashion, using the answer sheet to record your
findings. Be organized. Be compulsive. Be strict in your application of the ECG criteria. And
take your time — even the most experienced electrocardiographers miss important ECG
diagnoses when hurrying through an interpretation. Be sure to analyze the following 14 features on each
ECG, as outlined here and described in greater detail in Section 1:
01. Heart rate 08. QRS voltage
02. P wave morphology and amplitude 09. R wave progression in the precordial leads
03. Origin of the rhythm 10. Abnormal Q waves
04. PR interval 11. ST segment
05. QRS width 12. T wave
06. QT interval 13. U wave
07. QRS axis 14. Electronic pacemaker
Once these features have been identified, ask yourself the following questions:
1. Is an arrhythmia and/or conduction disturbance present?
2. Is chamber enlargement and/or hypertrophy present?
3. Is ischemia, injury, and/or infarction present?
4. Are any clinical disorders (items 70-89 on answer sheet) likely to be present?
It is important to consider each ECG in the context of the clinical history. For example, diffuse mild ST
segment elevation in an asymptomatic patient is likely to represent early repolarization abnormality,
whereas the same finding in a patient with chest pain and a friction rub is more likely to represent acute
pericarditis.
After coding the ECG on the accompanying answer sheet, study the correct interpretation. If ECG
diagnoses were missed or improperly selected, turn to the final section of the book and review the
appropriate criteria. The ECG criteria expressed in this book represent a consensus among the authors,
based on previously published literature and their own experience and viewpoints.
Answer the multiple choice and fill-in-the-blank questions corresponding to each ECG. Cover the
answer column as you work through the “Quick Reviews” and “Pop Quizzes” that follow each case.
Place a check mark next to the questions that were answered incorrectly; at the end of each reading
session and at the start of each new reading session, return to these questions and be sure they can be
answered correctly. Once all the ECGs have been interpreted and the questions answered, review them
again until they are mastered.
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