List of Contributors xxi Section I The ECG in Clinical Practice 1 1 The ECG in Clinical Medicine 3 Brian Kessen and Kelly Williamson Introduction 3 The ECG as a Clinical Tool 3 Clinical Presentations and the ECG 4 Chest Pain 4 Dyspnea 5 Syncope 6 Toxicology 7 Electrolyte Abnormalities 7 Pacemakers 10 Conclusion 10 References 10 2 History of the Electrocardiogram 13 Trale Permar and Kelly Williamson References 17 Section II ECG Changes in Myocardial Ischemia 19 1 The Cardiac Action Potential and Changes in the Setting of Acute Coronary Syndrome: How Ischemia and Infarction Impacts the ECG 21 Kirsti A. Campbell and Michael J. Lipinski Introduction 21 Basic Electrophysiology 21 Action Potentials in Sodium-Dependent Depolarizers 21 Action Potential in Calcium-Dependent Depolarizers 24 Anatomy of the Electrical Conduction System 24 Biochemical Impact of Ischemia 25 ST-Segment Deviation 25 QRS Complex 30 T Waves 31 P Waves 31 U Waves 34 Myocardial Ischemia: Causes Other than Acute Coronary Syndrome 34 Conclusion 34 References 36 2 Ischemic Electrocardiographic Changes and Correlation with Regions of the Myocardium 37 Thibault Lhermusier and Michael J. Lipinski Introduction 37 Coronary Anatomy 37 Definitions of STEMI and Non-ST Elevation ACS 38 Left Main Coronary Ischemia 39 Anterior STEMI 40 Wellens Syndrome 40 Inferior STEMI 41 Right Ventricular Infarction 41 Lateral STEMI 44 Posterior STEMI 44 Conduction Abnormalities in the Setting of Ischemia 46 Aneurysm of the Left Ventricle 49 ECG in Pharmacological and Mechanical Reperfusion 49 Conclusion 50 References 50 3 STEMI Mimics 53 Peter M. Pollak Introduction 53 Myocarditis and Myopericarditis 53 Early Repolarization 55 Left Ventricular Hypertrophy 57 Prior Infarction and Ventricular Aneurysm 58 Vasospasm (Prinzmetal or Variant Angina) 58 Apical Ballooning Syndrome (Takotsubo Cardiomyopathy) 61 Brugada Pattern and Idiopathic Ventricular Fibrillation 62 Hyperkalemia 62 Post-Cardioversion/Shock 62 Hypothermia and Osborn Waves 62 Pulmonary Embolism 63 Other Causes of ST Elevation 63 Conclusion 65 References 65 4 Confounders of ST Elevation Myocardial Infarction 69 Amy West Pollak Introduction 69 Left Bundle Branch Block 69 LBBB and Ischemic Heart Disease 69 Left Ventricular Hypertrophy 71 Ventricular Paced Rhythm 71 Right Bundle Branch Block (RBBB) 73 References 73 5 The Prognostic Value of the Electrocardiogram in Acute Coronary Syndromes 75 Benjamin Shepple and Robert Gibson Introduction 75 The ECG in Acute Coronary Syndromes 75 ST Elevation Myocardial Infarction (STEMI) 75 The ECG during Myocardial Injury 76 The ECG in Response to Therapy 80 ECG after Completion of Infarction 81 UA/NSTEMI 83 ST-Segment Depression 83 T-Wave Inversions 84 Initial Normal ECG 86 Arrhythmia and Conduction Disease 86 Ventricular Arrhythmias 86 Premature Ventricular Contractions 87 Ventricular Tachycardia 87 Ventricular Fibrillation 87 Supraventricular Tachycardia 89 AV Conduction Delay and Heart Block 90 Prolonged QTc Interval 91 Conclusion 92 References 92 6 ECG Tools: Alternate Lead Placement, Serial ECGs, and ECG Monitoring 97 Augustus E. Mealor, Yasir Akhtar, and Michael Ragosta Introduction 97 Right-Sided Leads 97 Posterior ECG 99 Serial ECG Monitoring 101 STM-ECG 101 Serial ECG Monitoring 101 References 105 7 Electrocardiographic Changes of Ischemia during Stress Testing 107 Michael J. Lipinski and Victor F. Froelicher Introduction 107 Exercise Physiology 108 Normal ECG Changes with Exercise 108 ECG Changes with Ischemia 109 Women 114 Diagnostic Scores 114 Termination of Exercise Testing 114 Exercise Testing and Acute Coronary Syndromes 117 Exercise Testing after Myocardial Infarction 117 Recommended Reading 120 Conclusions 120 References 120 Section III The Dysrhythmic ECG 123 1 Bradycardia 125 Andrew E.

Darby Introduction 125 Abnormalities of Sinus Node Function 125 Abnormalities of Atrioventricular Nodal Conduction 126 Indications for Cardiac Pacing 131 Conclusions 131 References 132 2 Atrioventricular (AV) Block 133 Mark Marinescu and Andrew E. Darby First-Degree AV Block 133 Second-Degree AV Block 133 Third-Degree AV Block 137 Indications for Permanent Pacing 137 Conclusions 138 References 138 3 The Dysrhythmic ECG: Intraventricular Block 141 Andrew E. Darby Introduction 141 Anatomy and Electrophysiology 141 Right Bundle Branch Block 141 Left Bundle Branch Block 143 Nonspecific Intraventricular Conduction Delay 145 Fascicular Block 145 References 146 4 Narrow QRS Complex Tachycardia 149 Augustus E. Mealor and Andrew E. Darby Introduction 149 Approach to the ECG Diagnosis of NCT 150 The Regular Narrow Complex Tachycardias 151 Paroxysmal Supraventricular Tachycardia 154 The Irregular Narrow Complex Tachycardias 158 References 160 5 Wide QRS Complex Tachycardia 161 Andrew E. Darby Ventricular Tachycardia 161 Ventricular Paced Rhythm 164 Diagnosis of Wide QRS Complex Tachycardia by Electrocardiogram 166 Conclusions 167 References 167 6 Non-Sinus Rhythms with Normal Rates 169 Will Dresen and Andrew E. Darby Introduction 169 Ectopic Atrial Rhythm 169 Accelerated Idioventricular Rhythm (AIVR) 172 Conclusions 172 References 172 7 Rhythms of Cardiac Arrest 173 Erich Kiehl and Andrew E. Darby Introduction 173 Torsade de Pointes 174 Preexcited Atrial Fibrillation 174 Pulseless Electrical Activity 177 Conclusions 179 References 179 8 Premature Atrial and Ventricular Complexes 181 Adrián I.

Löffler and Andrew E. Darby Premature Atrial Contractions 181 Premature Ventricular Contractions 184 References 186 9 Nontraditional Rhythm Disorders: Dysrhythmias Related to Metabolic and Toxicologic Conditions 187 Andrew E. Darby Introduction 187 Antiarrhythmic Drug Toxicity 188 Tricyclic Antidepressant Toxicity 190 Conclusions 191 References 192 10 Dysrhythmia-Related Syndromes 193 Michele Murphy and Andrew E. Darby Introduction 193 Dysrhythmia-Related Syndromes - Primary Electrical Abnormalities 193 Wolff-Parkinson-White Syndrome 193 Dysrhythmia-Related Syndromes - Primary Cardiac Structural Conditions 197 Conclusions 199 References 200 Section IV The ECG in Cardinal Presentations and Scenarios 201 1 The Patient with Cardiac Arrest 203 Michael Cirone, Mitchell Lorenz, and Karis Tekwani Introduction 203 Ventricular Fibrillation 203 Pulseless Ventricular Tachycardia 203 Asystole 205 Pulseless Electrical Activity 205 Conclusion 206 References 206 2 The Patient with Chest Pain 207 Paul Basel, Lane Thaut, and Nathan Olson Introduction 207 Acute Coronary Syndrome 207 Pericarditis 213 References 215 3 The Patient with Dyspnea 219 Adriana Segura Olson, Anders Messersmith, and Matthew Robinson Introduction 219 Pulmonary Embolism 219 Cor Pulmonale 220 Cardiomyopathy 220 Congestive Heart Failure 223 Pneumothorax 223 ASTHMA/COPD 224 Anaphylaxis/Kounis Syndrome 225 Metabolic 226 Summary 227 References 227 4 The Patient with Palpitations/Syncope 229 Natasha Wheaton, Emma Nash, and Jeffrey Brown Supraventricular Tachycardia 229 Atrial Fibrillation 229 Multifocal Atrial Tachycardia 230 Conduction Blocks 232 Brugada Syndrome 233 Hypertrophic Cardiomyopathy 234 Wolf-Parkinson-White Syndrome 234 Long QT Syndrome 236 Arrhythmogenic Right Ventricular Dysplasia 237 References 237 5 The Patient with Preoperative Evaluation 239 Sarah Chuzi, Jane Wilcox, and Lisa B. Van Wagner Introduction 239 Indications 239 Common ECG Abnormalities 239 Nonspecific ST-T Changes 244 Pathologic Q Waves 244 QT/QTc Prolongation 245 Conclusion 245 References 246 6 The Patient in Shock 249 Meagan R. Hunt and Nicholas D. Hartman Introduction 249 Cardiogenic Shock 249 Obstructive Shock 252 Distributive Shock 252 Hypovolemic Shock 262 Summary 262 R.