Easy ECG E-Book

Hans-Holger Ebert

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 95

Veröffentlichungsjahr: 2004

Beschreibung

The Guide to Electrocardiography fills a gap between the EKG atlas and textbooks based on electrophysiology. Starting with the relevant anatomical information, the book provides instructive EKG lead diagrams and clear schematic drawings that will help familiarize the reader with characteristic EKG patterns and electrophysiologic principles. Electrocardiographic phenomena and the electrophysiologic events that underlie them are linked to practical implications for clinical diagnosis and treatment, providing the reader with a competent guide for navigating the sometimes difficult depths and shoals of accurate EKG interpretation.

Leseprobe

Library of Congress Cataloging-in-Publication Data

Ebert, Hans-Holger.

[EKG-Lotse English]

Easy ECG: interpretation, differential diagnoses / Hans-Holger Ebert; translated by Janine Manuel.

p.; cm

Includes index.

ISBN 3-13-135641-3 (GTV: alk. paper) –

ISBN 1-58890-286-2 (TNY: alk. paper)

1. Electrocardiography.

[DNLM: 1. Electrocardiography–Handbooks.

2. Arrhythmia–diagnosis–Handbooks.

3. Diagnosis, Differential–Handbooks.

WG 39 E16e 2004a] I. Title.

RC683.5.E5E23613 2004

616.1'207547–dc22

2004015293

This book is an authorized translation of the German edition published and copyrighted 2001 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Der EKG-Lotse.

Translator: Janine Manuel, M.D.,

Dortmund, Germany

© 2005 Georg Thieme Verlag,

Rüdigerstrasse 14, 70469 Stuttgart,

Germany

www.thieme.de

Thieme New York, 333 Seventh Avenue,

New York, NY 10001 USA

www.thieme.de

Cover design: Martina Berge, Erbach

Typesetting and graphics by Ziegler + Müller, Kirchentellinsfurt

Printed in Germany by Druckhaus Götz, Ludwigsburg

ISBN 3-13-135641-3 (GTV)

1 2 3 4 5

ISBN 1-58890-286-2 (TNY)

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers' leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed.

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher's consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

For Elena, Daniela, and my parents

Contents

1 The Human Heart

1.1 Basic Anatomy

1.2 Anatomy of the Conduction System

1.3 The Sinus Node

1.4 The Compact AV Node

1.5 The Bundle of His

1.6 The Bundle Branches

1.7 The Slow Pathway Region

1.8 The Fast Pathway Region

1.9 The Isthmus Region

2 The Conduction Diagrams and Text Fields

2.1 Basic Concepts

2.2 Impulse Formation in the Sinus Node

2.3 Depolarization of the Atria (P Wave)

2.4 Conduction of the AV Node

2.5 Depolarization of the Ventricles

2.6 Further Explanations

3 Cardiac Rhythm Disorders and Conduction Disorders

3.1 Sinus Arrythmias

3.2 AV Conduction Disorders

3.3 Right Bundle Branch Block

3.4 Left Bundle Branch Block

3.5 Mixed Types of Block

3.6 Supraventricular Extrasystole

3.7 Atrial Tachycardia

3.8 “Atypical” Atrial Flutter

3.9 “Typical” Atrial Flutter

3.10 Atrial Fibrillation

3.11 Reentry Tachycardia

3.12 Ventricular Extrasystole

3.13 Ventricular Tachycardia

3.14 Ventricular Flutter

3.15 Ventricular Fibrillation

4 Coronary Heart Disease and Myocardial Infarction

4.1 Coronary Anatomy

4.2 Stress-Induced Ischemia in Coronary Heart Disease

4.3 Acute Coronary Syndrome

4.4 Acute Myocardial Infarction

4.5 Resting Ischemia in the Anterior Wall Region Following Posterior Wall Infarction

4.6 Stress-Induced Ischemia in the Infarct Region Following Posterior Myocardial Infarction

5 Other ECG Changes

5.1 Left Ventricular Hypertrophy

5.2 Hypertrophic Obstructive Cardiomyopathy

5.3 Mitral Valve Prolapse Syndrome

5.4 Pericarditis and Myocarditis

5.5 Right Ventricular Hypertrophy

5.6 Acute Pulmonary Embolism

5.7 Dextrocardia

5.8 Arrhythmogenic Right Ventricular Dysplasia

5.9 Brugada Syndrome

5.10 QT Syndrome

5.11 Medication-Related ECG Changes

5.12 ECG Changes With Electrolyte Shifts

5.13 P Wave Changes

Literature

Index

Acknowledgements

My deepest thanks to Dr. Thomas Reimann for his extensive efforts in preparing the way and support in the production of this book.

My greatest thanks go to Prof. Volkmann (Senior Consultant at the Erzgebirgsklinikum Annaberg-Buchholz) and to Dr. S. G. Spitzer (Head of the Department of Electrophysiology and Pacemaker Therapy, Group Practice Dresden) for the many years of fruitful cooperation and for all the knowledge they have imparted.

Furthermore, I would like to thank all my colleagues in and around Dresden and Riesa, working in hospitals and private practices, who with their numerous and important suggestions have contributed to the success of this book.

Riesa,

Hans-Holger Ebert

Summer 2004

Foreword

Why do we need another ECG book when so many good, and some not so good, ECG textbooks, atlases, manuals, and guides are available? My former colleague of many years, Dr. Hans-Holger Ebert, has written an ECG guide which bridges the gap between the ECG atlases and textbooks based on electrophysiology. It gives the reader a closer understanding of the subject, including valuable ECG conduction diagrams, which can be used for teaching purposes, and clear, standardized schematic diagrams. Corresponding characteristic ECGs and the basics of electrophysiology are explained in a manner which makes them easily comprehensible. Konrad Spang, one of the pioneers of cardiology in Germany, said in 1957: “The correct interpretation of rhythm disorders often demands great effort and detailed in-depth analysis. Conducting such analyses is of huge didactic value. This is a pathway for the development of the ability to make exact observations and also sharpens the senses in other areas…”

Easy ECG meets these demands. The author has linked electrocardiographic phenomena and the underlying electrophysiological principles with practical conclusions for clinical diagnosis and treatment. Many years of experience in cardiology in hospital and outpatient settings have been of value to the author, and the numerous internships he has supervised and lectures he has given have benefited his teaching skills.

I hope Easy ECG will draw many interested readers and contribute to an in-depth understanding of current diagnostic and therapeutic options to be derived from ECG analysis, just as a pilot boat guides ships safely in and out the harbor.

Hans Volkmann

Professor and Senior Consultant

Internal Medicine

Erzgebirgsklinikum Annaberg

1 The Human Heart

1.1 Basic Anatomy

1.2 Anatomy of the Conduction System

1.3 The Sinus Node

Size/form: 10–20 mm, spindle-shaped

Location:

In the first third of the sulcus terminalis along the axis between the opening of the superior vena cava and the right subepicardial auricle

Blood supply:

Sinus node artery (arises from RCA in 50–59%, from RCX in 20–38%, dual blood supply in 3–30%)

Innervation:

Parasympathetic postganglionic and sympathetic fibers

Function: Physiological site of impulse formation

Electrophysiological significance:

Site of sinus node reentry

1.4 The Compact AV Node

Size/form: ca. 1×3×5mm

Location:

Base of the right atrium at the point of the so-called Koch triangle (between the tricuspid annulus and the eustachian valve), subendocardial

Blood supply:

AV node artery (arises from RCA in 90%, in 10% from RCX)

Innervation:

Parasympathetic postganglionic and sympathetic fibers

Function:

Impulse conduction from the atrium to the bundle of His

Electrophysiological significance:

Secondary site for impulse formation, area of slowest impulse conduction (0.2 m/s)

1.5 The Bundle of His

Size/form: 10–20mm

Location:

Continuation of the compact AV node, penetrates the annulus fibrosus, subendocardial course in the pars membranacea of the interventricular septum

Blood supply:

AV node artery (90% from RCA, 10% from RCX)

Innervation:

Parasympathetic postganglionic and sympathetic fibers

Function:

Impulse conduction from the compact AV node to the bundle branches

Electrophysiological significance:

Possible blockade of AV conduction

1.6 The Bundle Branches

Right bundle branch:

Extension of the bundle of His coursing along the right aspect of interventricular septum

Left bundle branch:

Runs through the ventricular septum to the left and divides into two branches: the inferoposterior and the superoanterior

Innervation:

Parasympathetic and sympathetic

Function:

Conduction of the electrical impulse to the myocardium

1.7 The Slow Pathway Region

Size/form: Variable expansion of the fibers

Location:

Between the opening of the coronary sinus and the compact AV node (posteroinferior to the compact AV node)

Innervation and blood supply:

No reliable data to date

Function:

Transition zone between the atrial myocardium and the compact AV node

Electrophysiological significance:

Very premature impulses are conducted with delay; essential component of AV node reentry tachycardia

1.8 The Fast Pathway Region

Size/form: Variable expansion of the fibers

Location:

In the region of the intraatrial septum anterosuperior to the KOCH triangle

Innervation and blood supply:

No reliable data to date

Function:

Transition zone between the atrial myocardium and the compact AV node

Electrophysiological significance:

Very premature impulses are not conducted; essential component of AV node reentry tachycardia

1.9 The Isthmus Region

Size/form: Variable expansion of the area

Location:

Between the tricuspid valve, inferior vena cava, and the opening of the coronary sinus

Innervation and blood supply:

No reliable data to date

Function:

Region of delayed impulse conduction

Electrophysiological significance:

Essential component of reentry circuit in typical atrial flutter

2 The Conduction Diagrams and Text Fields

2.1 Basic Concepts

The conduction diagram represents a simplified projection of impulse conduction at the various anatomical levels of the heart on a time axis. Using typical ECG recordings a 1:1 correlation of the impulse components is made with the anatomical levels. The arrows are designed to help with recognition of the start of sinus rhythm and of the P wave.

2.2 Impulse Formation in the Sinus Node

The formation of the electrical impulse in the sinus node is necessary to give rise to so-called sinus rhythm. Formation of an impulse in the sinus node is not conspicuous in the superficial ECG itself and can only be detected indirectly from atrial depolarization (P wave).

To better explain rhythm disorders in the region of the sinus node, impulse formation and conduction at the sinus node are represented schematically using a dotted arrow ( in the ECG) and schematically in the diagrams by a dotted line ().

2.3 Depolarization of the Atria (P Wave)

The first electrical activity conspicuous in sinus rhythm is depolarization of the atria; a P wave occurs. The beginning of the P wave is indicated by a solid arrow () and in the diagrams by a solid line (\).

In sinus rhythm the P wave has the largest positive deflection in lead II (the atrial vector runs parallel to lead II in sinus rhythm).

The occurrence of supraventricular extrasystoles (SVES) is indicated by a dot with two arrows () and always occurs midway at atrial level.

2.4 Conduction of the AV Node