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The Only
EKG
BOOK
You’ll Ever Need
NINTH EDITION
MALCOLM S. THALER, M.D.
Physician, Internal Medicine, One Medical
Clinical Instructor in Medicine, Weill Cornell Medical College
Medical Staff, New York Presbyterian Hospital
New York, New York
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Ninth edition
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Printed in China
Library of Congress Cataloging-in-Publication Data
Names: Thaler, Malcolm S., author.
Title: The only EKG book you’ll ever need / Malcolm S. Thaler.
Description: Ninth edition. | Philadelphia : Wolters Kluwer, [2019] | Includes index.
Identifiers: LCCN 2017053867 | eISBN 9781975106072
Subjects: | MESH: Electrocardiography | Heart Diseases—diagnosis | Case Reports
Classification: LCC RC683.5.E5 | NLM WG 140 | DDC 616.1/207547—dc23 LC record available
at https://lccn.loc.gov/2017053867
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Dedication
For Nancy, Ali, Jon, and Tracey too–as well as for everyone toiling in the health
care profession, trying to make people’s lives happier and healthier.
Preface
The torrid pace of technologic and scientific evolution shows no signs of letting
up, and clinical medicine is both its beneficiary and, conspicuously, its victim,
too, as we seem to have less and less time to actually spend with our patients. It
is therefore comforting to know that at least one old friend still stands tall—the
EKG. Almost 30 years have passed since the first edition of this little book, and
nothing has yet supplanted the EKG as the essential tool for diagnosing many
cardiac disorders (and many noncardiac ones as well). Does your patient have
chest pain?—get an EKG! Does your patient have palpitations?—get an EKG!
Syncope or dizziness?—you get the point.
These three decades have not dimmed the principles outlined in the preface to
the first edition:
This book is about learning. It’s about keeping simple things simple, and
complicated things clear, concise and, yes, simple, too. It’s about getting from
here to there without scaring you to death, boring you to tears, or intimidating
your socks off. It’s about turning ignorance into knowledge, knowledge into
wisdom, and all with a bit of fun.
If I were writing this today, I would probably reword that business about the
socks, but the sentiments remain and are, I hope, ones you share. New material
has been added as new developments—and there have been many—have called
for it, and everything is always discussed within its proper clinical context by
putting you, the reader, right in the middle of real life situations. EKG’s are not
used in isolation; they are just one piece—albeit an important piece—of the
puzzle that every patient presents and that you and I have to figure out over and
over again.
I want to offer a very special thanks to Dr. Adam Skolnick, M.D., Associate
Professor of Medicine, Leon H. Charney Division of Cardiology, NYU Langone
Medical Center, whose keen editorial eye, incisive analysis, and unsurpassed
expertise are the best guarantee that you will be reading the most current, clear,
and accurate text that anyone could hope for. And allow me to add a shout out to
Dr. Jeffrey Lorin, Assistant Professor of Medicine at NYU Medical Center, who
graciously opened up his world-class collection of EKG’s so that we all could
benefit.
A special thank you as always to the wonderful folks at Wolters Kluwer—let
me give a very personal standing ovation to Kristina Oberle and Rebecca
Gaertner—who always produce a beautiful, polished, limpid book (and have the
good sense to edit out words like limpid when words such as clear and readable
are far more serviceable and, well, limpid). They make every edition a joy to
work on.
For those of you picking up this book for the first time—as well as for those
of you coming back for a return visit—I hope The Only EKG Book You Will Ever
Need provides you with everything you need to start reading EKG’s quickly and
accurately.
Malcolm S. Thaler, M.D.
Contents
Getting Started
Chapter 1
The Basics
Electricity and the Heart
The Cells of the Heart
Time and Voltage
P Waves, QRS Complexes, T Waves, and Some Straight Lines
Naming the Straight Lines
Summary: The Waves and Straight Lines of the EKG
Making Waves
The 12 Views of the Heart
A Word About Vectors
The Normal 12-Lead EKG
Summary: Orientation of the Waves of the Normal EKG
Some Really Important Stuff That You May Be Wondering: Part 1: Why Not Just Let the Computer
Do It?
Some Really Important Stuff That You May Be Wondering: Part 2: How Do I Get the Goop Off My
Patient’s Chest Once the EKG Is Finished?
Coming Attractions
Chapter 2
Hypertrophy and Enlargement of the Heart
A Few Introductory Remarks
Definitions
Axis
Summary: Axis
Axis Deviation, Hypertrophy, and Enlargement
Atrial Enlargement
Summary: Atrial Enlargement
Ventricular Hypertrophy
Secondary Repolarization Abnormalities of Ventricular Hypertrophy
Summary: Ventricular Hypertrophy
CASE 1
CASE 2
Chapter 3
Arrhythmias
The Clinical Manifestations of Arrhythmias
Why Arrhythmias Happen
Rhythm Strips
How to Determine the Heart Rate From the EKG
The Five Basic Types of Arrhythmias
Arrhythmias of Sinus Origin
Summary: Arrhythmias of Sinus Origin
Ectopic Rhythms
Reentrant Rhythms
The Four Questions
Supraventricular Arrhythmias
Summary: Supraventricular Arrhythmias
Ventricular Arrhythmias
Summary: Ventricular Arrhythmias
Supraventricular Versus Ventricular Arrhythmias
Summary: Ventricular Tachycardia Versus Supraventricular Tachycardia With Aberrancy
Electrophysiology Studies (EPS)
Implantable Defibrillators
External Defibrillators
CASE 3
CASE 4
CASE 5
Chapter 4
Conduction Blocks
What Is a Conduction Block?
AV Blocks
Summary: AV Blocks
Bundle Branch Block
Summary: Bundle Branch Block
Hemiblocks
Combining Right Bundle Branch Block and Hemiblocks
Blocks That Underachieve
The Ultimate in Playing With Blocks: Combining AV Blocks, Right Bundle Branch Block, and
Hemiblocks
Pacemakers
CASE 6
CASE 7
CASE 8
Chapter 5
Preexcitation Syndromes
What Is Preexcitation?
Wolff–Parkinson–White
A Short PR Interval Without a Delta Wave
Why Do We Care About Preexcitation?
Summary: Preexcitation
CASE 9
Chapter 6
Myocardial Ischemia and Infarction
Stable Angina and Acute Coronary Syndromes
How to Diagnose a Myocardial Infarction
ST-Segment Elevation Myocardial Infarctions (STEMIs)
Summary: The EKG Changes of an Evolving STEMI
Localizing the Infarct
Non–ST-Segment Myocardial Infarctions (non-STEMIs)
Takotsubo Cardiomyopathy
Angina Without Infarction
Sorting Out the Different Ischemic Syndromes
Limitations of the EKG in Diagnosing an Infarction
Stress Testing
CASE 10
CASE 11
