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Contents
Foreword vii
Preface
Introduction by Bernhard Meier x
Acknowledgements xi
Abbreviations xxxiii
Section I Theoretical Basics and Practical Approach
Introduction and Concept of the Book 1
Introduction 1
The Value of `the ECG'Today 1
Limitations of the Pattern EGG 1
Conclusions 2
Concept of the Book 2
Chapter 1
Theoretical Basics 3
1 Anatomy of the Impulse Formation and Impulse
Conduction Systems 3
2 Normal Impulse Conduction 3
3 Action Potential of a Single Cell of Working Myocardium
and its Relation to Ion Flows 4
4 Atrial Depolarization and Repolarization 5
5 Ventricular Depolarization and Repolarization 6
5.1 Vectors and Vectorcardiogram 6
5.2 Simplified QRS Vectors 6
6 Lead Systems 7
7 `Magnifying Glass' and `Proximity' Effects 7
8 Refractory Period 9
9 Nomenclature of the ECG 9
References 11
Chapter 2
Practical Approach 13
1 The Practical Approach 14
1.1 Definitive ECG diagnosis 15
2 Practical approach 16
2.1 Analysis of rhythm 16
2.2 Detailed analysis of morphology 17
References 18
Section II Pattern ECG
Chapter 3
The Normal ECG and its (Normal) Variants 19
1 Components of the Normal ECG 19
1.1 Sinus Rhythm 19
1.1.1 Atrial Vectors in Sinus Rhythm 20
1.2 PQ Interval 21
1.3 QRS complex 21
1.3.1 QRS Axis in the Frontal Plane (AQRSF) 21
1.3.2 QRS Axis in the Horizontal Plane 22
1.3.3 Two Special QRS Patterns 22
1.3.4 Other Normal Variants of the QRS Complex 22
1.4 ST Segment 23
1.4.1 Common Pattern of ST elevation: ST elevation in
V2/V3 23
1.4.2 Rare Pattern of ST Elevation: Early Repolarization 24
1.5 T Wave and U Wave 24
1.5.1 T Wave 24
1.5.2 U Wave 25
1.6 QT Interval 25
1.7 Arrhythmias 25
1.8 Day-to-Day and Circadian Variation 26
General Conclusion 27
References 27
Chapter 4
Atria) Enlargement and Other Abnormalities of the p Wave
45
1 Left Atrial Enlargement (p Mitrale) 45
2 Right Atrial Enlargement (p Pulmonale) 45
3 Biatrial Enlargement (p Biatriale) 45
4 Acute Left Atrial Overload 46
5 Acute Right Atrial Overload 46
6 Other Abnormalities of the p Wave 46
7 Etiology, Prevalence and Clinical Significance of Left
Atrial Enlargement 46
8 Etiology, Prevalence and Clinical Significance of Right
Atrial Enlargement 47
9 Vectors in Left Atrial Enlargement 47
10 Vectors in Right Atrial Enlargement 47
11 Special Alterations of the p Wave 47
11.1 So-called `p Pulmonale Vasculare 47
11.2 p Pseudo-Pulmonale 48
11.3 Imitation of p Pulmonale 48
11.4 p Biatriale/Biatrial Enlargement 48
11.5 Other Uncommon p Configurations in Sinus Rhythm48
11.5.1 Negative p Wave in Lead I 48
11.5.2 Ebstein's Anomaly 48
11.5.3 Atrial Infarction 48
11.5.4 Tricuspid Atresia 48
References 48
Chapter 5
Left Ventricular Hypertrophy 53
1 ECG Indices for LVH 53
2 Diagnosis of LVH in Intraventricular Conduction
Disturbances 54
3 Etiology and Prevalence 54
4 Validation of the QRS Voltage Criteria 55
5 Detection of LVH in Ventricular Conduction Disturbances
55
5.1 Right Bundle-Branch Block 56
5.2 Left Bundle-Branch Block 57
5.3 Left Anterior Fascicular Block 57
5.4 Other Ventricular Conduction Disturbances 58
6 Detection of LVH in Special Conditions 58
6.1 Hypertrophic Obstructive Cardiomyopathy 58
6.2 Asymmetrical Apical LVH 59
6.3 Systolic and Diastolic Overload 59
6.4 LVH Associated with Marked IV Dilatation 59
7 Factors Impairing the ECG Diagnosis of LVH 59
7.1 Gender and Race 59
7.2 Age 59
7.3 Body Habitus and Body Weight 59
7.4 Other Pathologic Conditions 59
7.5 Variability of the Frontal and Horizontal QRS Vector 60
8 Conclusions 60
9 Pathophysiology and Effects of LVH on the ECG 60
10 Prognosis of LVH 6o
References 6o
Chapter 6
Right Ventricular Hypertrophy 75
1 ECG Conditions for RVH 75
1.1 RVH without RV Conduction Disturbance 75
1.2 RVH with iRBBB (QRS Duration Normal) 75
1.3 RVH with RBBB (QRS Duration > 0.12 sec) 76
2 Etiology and Prevalence 76
3 Vectors in RVH 76
4 RVH in the ECG 77
4.1 Single R Wave, QR Complex or RS Complex in Lead V
77
4.2 Incomplete Right Bundle-Branch Block 77
4.3 Complete Right Bundle-Branch Block 77
4.4 SI/SII/SIIIType 77
4.5 Rare Type of RVH 78
4.6 P Wave Alterations 78
5 Differential Diagnosis of Possible Signs of RVH 78
5.1 Frontal QRS Right-Axis Deviation 78
5.2 qR Type in Lead V 78
5.3 Tall R Wave and RS Complex in Lead V 78
5.4 Incomplete Right Bundle-Branch Block 79
5.5 Complete Right Bundle-Branch Block 79
5.6 SI/SII/SIIIType 79
6 Systolic and Diastolic Overload 79
7 Effect of Systolic Pressure in the Right Ventricle and
Pulmonary Artery on the ECG 79
References 79
Chapter 7
Biventricular Hypertrophy 89
1 Usual ECG Signs for BVH 90
2 Other ECG Signs for BVH 90
2.1 Shallow SV,,Deep SV2 90
2.2 Katz-Wachtel Sign 90
2.3 Special QRS Pattern in Right Bundle-Branch Block 90
References 90
Chapter 8
Pulmonary Embolism 95
1 ECG Alterations 95
1.1 Alterations of QRS 95
1.2 Alterations of Repolarization 95
1.3 Rhythm Disturbances 95
1.4 Alterations of the P Wave 95
2 Value of ECG in Suspected Acute PE 96
2.1 Differentiation of AMI from Acute PE 96
2.2 Analysis of Heart Rhythm and Conduction Disturbances
96
2.3 ECG Signs of Acute RV Overload 96
2.4 Control of Clinical Evolution 97
2.5 Subacute and Chronic repetitive PE 97
3 Prevalence of ECG Signs Suggesting PE 97
4 ECG Signs and Grade of Acute PE 98
5 Practical Procedures in Suspected Acute PE 98
6 ECG in Subacute PE 99
7 Historical Perspective 99
References l00
Chapter 9
Fascicular Blocks 105
Etiology and Prevalence 105
1 Left Anterior Fascicular Block 105
2 Left Posterior Fascicular Block 105
3 Intraventricular Conduction System Anatomy 106
4 Etiology of Fascicular Blocks l06
4.1 Etiology of LAFB l06
4.2 Etiology of LPFB 107
5 Left Anterior Fascicular Block 107
5.1 Vectors and the ECG 107
5.2 Variants 108
5.3 Prognosis 109
6 Left Posterior Fascicular Block 109
6.1 Vectors and the ECG 109
6.2 Special Remarks: AQRSF, ECG Patterns and Etiology
109
6.3 Prognosis 110
7 Very Rare Patterns of Fascicular Blocks 111
7.1 LAFB plus LPFB 111
7.2 Left Septal Fascicular Blocks 111
7.3 Right Fascicular Blocks 111
References 111
Chapter 10
Bundle-Branch Blocks (Complete and Incomplete) 117
1 Complete Right Bundle-Branch Block 117
2 Incomplete Right Bundle-Branch Block 118
3 Complete Left Bundle-Branch Block 118
4 Incomplete Left Bundle-Branch Block 118
5 Etiology and Prevalence 118
6 Complete Right Bundle-Branch Block 119
6.1 QRS Vectors 119
6.2 Repolarization Vectors 120
6.3 Determination of Frontal QRS Axis in RBBB 120
6.4 Myocardial Infarction in RBBB 120
6.5 Right Ventricular Hypertrophy in RBBB 120
7 Incomplete Right Bundle-Branch Block 120
8 Complete Left Bundle-Branch Block 121
8.1 QRS Vectors 121
8.2 Repolarization Vectors 122
8.3 Determination of Frontal QRS Axis in LBBB 122
8.4 Myocardial Infarction in LBBB 122
8.5 Left Ventricular Hypertrophy in LBBB 122
8.6 Incomplete Left Bundle-Branch Block 122
9 Special Aspects of Bundle-Branch Blocks 122
9.1 Rate-Dependent Bundle-Branch Block 122
9.2 Alternating, Intermittent and Reversible BBB 122
9.3 Difference of QRS and QT Duration in RBBB and
LBBB 123
to Prognosis 123
References 123
Chapter 11
Bilateral Bifascicular (Bundle-Branch) Blocks 131
1 RBBB + LAFB 131
2 RBBB + LPFB 132
3 Prognosis 132
4 Etiology 132
5 Differential Diagnosis of RBBB + LAFB 133
6 Differential Diagnosis of RBBB + LPFB 133
7 Differential Diagnosis of RBBB + LAFB + LPFB Without
Complete AV Block 133
8 Prognosis 134
9 Indications for Pacemaker Implantation 134
References 134
Chapter 12
Atrioventricular Block and Atrioventricular Dissociation
145
1 Anatomic Localization of AV Block 145
2 Degrees of AV Block 145
2.1 AV block l° 145
2.2 AV block 2° 146
2.2.1 AV block 20 Type Wenckebach 146
2.2.2 AV block 20 Type Mobitz 146
2.2.3 AV block 20 Type Advanced 146
2.3 Complete AV Block 146
2.4 Types of Complete AV Block 146
2.4.1 Infra-His Complete AV Block 146
2.4.2 Supra-His Complete AV Block 147
3 AV Dissociation 147
3.1 Three Types of AV Dissociation 147
3.1.1 AV Dissociation with Accrochage 147
3.1.2 Isorhythmic AV Dissociation 148
3.1.3 AV Dissociation with Interference 148
4 Nomenclature and its Implications 148
4.1 Differences Between Complete AV Block and AV
Dissociation 148
4.2 Pathophysiology and the ECG 148
4.3 Clinical Significance 149
5 Atrioventricular Block 149
5.1 AV Block 10 149
5.1.1 Hemodynamics in AV Block 10 149
5.2 AV block 2° 149
5.2.1 AV Block 2' Type Wenckebach 150
5.2.2 AV Block 2' Type Mobitz 150
5.2.3 AV Block 2° Type Advanced (High Degree) 151
5.3 AV Block 3° 151
5.3.1 Simultaneous Supra-His AV Block and Bundle-Branch
Block 152
5.3.2 AV Blocked Atrial Premature Beats 152
5.3.3 Development of Complete AV Block 152
5.3.4 Etiology and Clinical Significance of Complete AV
Block 153
5.3.5 His Bundle Derivations 154
5.3.6 ECG and Anatomical Lesions 154
5.3.7 Therapeutic Conclusions 154
6 Special AV Dissociation 154
6.1 Special Conditions in AV Dissociation 154
6.1.1 AV Dissociation in a Postextrasystolic Beat 154
6.1.2 Ventriculophasic Sinus Arrhythmia 155
6.1.3 AV Dissociation in Ventricular Tachycardia 155
References 155
Chapter 13
Myocardial Infarction 167
Etiology 167
1 ST Vectors, Q Vectors and T Vectors 167
2 Stages of Myocardial Infarction 168
2.1 Acute Stage 168
2.2 Subacute Stage 168
2.3 Old (Chronic) Stage 168
3 Localization of Q-Wave Infarction 169
3.1 Anteroseptal Infarction 169
3.2 Extensive Anterior (Anterolateral) Infarction 169
3.3 Lateral Infarction (Isolated MI of the Lateral Wall) 169
3.4 Inferior Infarction 169
3.5 Posterior ('True' Posterior) Infarction 169
3.6 Right Ventricular Infarction 171
4 Differential Diagnosis of `Classical' Infarction Patterns
(Pathologic Q waves, ST Elevation, Abnormal T Waves)172
5 Complex Infarction Patterns 173
6 Special Infarction Patterns 174
Conclusion 174
7 Etiology and Prevalence 175
7.1 Arteriosclerotic Coronary Artery Disease (Common)
175
7.2 Congenital Coronary Artery Disease (Rare) 175
7.3 Other Conditions of Coronary Artery Disease (Rare) 175
8 Nomenclature of Infarction Stages 176
8.1 Electropathophysiologic Evolution 176
8.2 International Terminology 177
8.3 Histopathologic Evolution 177
8.4 Clinical Findings and Practical Experience 177
9 Combination of Infarction Patterns 177
9.1 Infarction of Adjacent Areas 177
9.2 Infarction of Separate or Opposite Localization 178
10 Complex Infarction Patterns 178
10.1 Infarction Associated with Right Bundle-Branch Block
178
10.2 Infarction Associated with Left Bundle-Branch Block
179
10.2.1 Infarction in Pacemaker Patients 180
10.3 Infarction in Left Anterior Fascicular Block 180
10.4 Infarction in Left Posterior Fascicular Block 181
10.5 Infarction in Bilateral Block 181
10.5.1 Infarction in RBBB + LAFB 181
10.5.2 Infarction in RBBB + LPFB 181
ii Special Infarction Patterns 181
11.1 The So-Called Non-Q-Wave Infarction 181
11.2 Infarction with ST depression >_ 3 mm 182
11.3 Infarction with `Nonsignificant' Q Waves at Usual
Localization 182
11.4 Infarction with `Nonsignificant' Q Waves at Unusual
Localization 183
11.5 Infarction with RSR' Type in Precordial (and Inferior)
Leads 183
11.6 Infarction with Pure or Predominant Reduction of R
Wave Amplitude 183
11.7 Atrial Infarction 183
12 Differential Diagnosis of `Classical' Q-wave Infarction
Patterns 184
13 Localization of Infarction and Localization of Coronary
Occlusion 184
14 Estimation of Infarct Size 184
15 Electropathophysiology 185
15.1 Acute Stage 185
15.2 Subacute Stage 185
15.3 Old (Chronic) Stage 185
16 Complications of Acute MI 186
16.1 Arrhythmias and Conduction Defects 186
16.2 Nonarrhythmic Complications 186
References 186
Chapter 14
Differential Diagnosis of Pathologic Q waves 265
Definition of Normal Q Wave 265
Definition of (Formally) Pathologic Q Wave 265
1 Myocardial Infarction 265
1.1 New Q Waves 265
1.2 ST Elevation 266
1.3 Negative T Waves 266
2 Normal Variants 266
2.1 Frontal Plane 266
2.2 Horizontal Plane 266
3 Left Ventricular Hypertrophy 266
4 False Lead Poling 266
5 Left Bundle-Branch Block 266
6 Pre-Excitation (Wolff-Parkinson-White Syndrome) 267
7 Hypertrophic Obstructive Cardiomyopathy 267
8 Congenital Corrected Transposition of the Great Arteries
267
9 Situs Inversus 267
1o Q Waves after Pneumectomy 268
ii Q Waves in Pneumothorax 268
12 Q Waves after Pericardectomy 268
13 Q waves in Amyloidosis of the Heart 268
14 Pseudo-Q Wave due to Retrograde Atrial Activation 268
15 A Rarity: Q Waves in Muscular Dystrophy Steinert 268
16 QR Complex in Lead V1 268
17 Q Wave in Lead V1 in Right Atrial Dilatation 268
References 269
Chapter 15
Acute and Chronic Pericarditis 283
Etiology 283
1 Acute Pericarditis 283
2 Chronic Pericarditis 284
3 Etiology and Prevalence 284
4 PQ Depression 284
5 ST Elevation and ST Vector 284
6 Differential Diagnosis of Acute Pericarditis versus Acute
MI 284
6.1 ST Elevation 285
6.1.1 Amplitude of ST Elevation 285
6.1.2 Configuration of ST Elevation 285
6.1.3 ST Elevation in Frontal ECG Leads and Frontal ST
Vector 285
6.1.4 ST Elevation in Horizontal Leads 285
6.2 Pathologic Q Wave 286
6.3 PQ Depression 286
6.4 T-Wave Negativity 286
7 General Differential Diagnosis of ST Elevation 286
8 Arrhythmias 288
9 Chronic Pericarditis 288
1o Cardiac Tamponade 288
ii Clinical Findings in Acute Pericarditis 288
References 288
Chapter 16
Electrolyte Imbalances and Disturbances 299
1 Hyperkalemia (Hyperpotassemia) 299
2 Hypokalemia (Hypopotassemia) 299
3 Hypercalcemia 299
4 Hypocalcemia 300
5 Therapy of Potassium Imbalance 300
5.1 Severe Hyperkalemia 300
5.2 Severe Hypokalemia 300
6 Hyperkalemia (Hyperpotassemia) 300
6.1 Differential Diagnosis of Tall and Peaked T waves 301
6.2 Prevalence, Clinical Findings and Etiology of
Hyperkalemia 301
6.3 Therapy of Severe Hyperkalemia 302
7 Hypokalemia (Hypopotassemia) 302
7.1 Pathophysiology of Hyperkalemia and Hypokalemia 303
8 Hypercalcemia 303
9 Hypocalcemia (Isolated or Associated with Hyperkalemia)
303
1o Hypomagnesemia 303
11 Hypermagnesemia 303
12 Sodium Imbalance 304
13 New Classification of Antiarrhythmic Drugs 304
References 304
Appendix 1 Etiology 305
Chapter 17
Alterations of Repolarization 323
1 ST Segment 323
1.i ST Elevation 323
1.2 ST Depression 323
2 T Wave 324
2.1 T Negativity 324
2.2 T Positivity 324
3 Special Remarks 325
3.1 Atypical Behavior of Repolarization in Acute
Myocardial Infarction and Acute Pericarditis ... 325
3.2 Patterns with Prolonged or Shortened QT Duration 325
3.3 Giant Negative T Waves 325
References 326
Section III Arrhythmias
Chapter 18
Atrial Premature Beats 329
1 Prevalence and Clinical Findings 330
2 Therapy 330
References 331
Chapter 19
Atrial Tachycardia 337
1 `Salvos' of Atrial Premature Beats 337
2 'Benign' Atrial Tachycardia 337
3 Atrial Tachycardia of Medium Duration and High Rate
337
4 `Incessant'AtrialTachycardia 337
5 Atrial Tachycardia with Atrioventricular Block 2 337
6 Multifocal Ectopic Atrial Tachycardia (Chaotic Atrial
Mechanism) 337
7 Ectopic (Focal) Atrial Tachycardia 338
8 Atrial Reentry Tachycardia 338
9 Repetitive Paroxysmal Atrial Tachycardia 338
to Paroxysmal Atrial Tachycardia with AV Block 338
ii Left Atrial Tachycardia 339
12 Multifocal Atrial Tachycardia (Chaotic Atrial
Tachycardia) 339
13 Accelerated Atrial Rhythm 339
14 Closing Remarks 339
References 339
Chapter 20
Atrial Flutter 347
1 Morphologic Types of Atrial Flutter 347
i.i Common Type (Type i) 347
1.2 Uncommon Type (Type 2) 347
2 Nomenclature 348
3 Etiology 349
4 Clinical Significance 349
5 Pathophysiology and Therapeutic Consequences 350
References 350
Chapter 21
Atrial Fibrillation 363
Etiology and Prevalence 363
1 Hemodynamics 363
2 Clinical Significance 364
3 Therapy 364
4 Etiology and Prevalence 364
5 Aberration in Atrial Fibrillation 365
5.1 Ashman Beats 365
5.2 Atrial Fibrillation in Pre-excitation
(Wolff-Parkinson-White Syndrome) 365
6 Regular Ventricular Action in AF 365
7 Interatrial Dissociation in AF 366
8 Differential Diagnosis 366
9 Electrophysiology 366
lo Clinical Significance 367
ii Therapy and Prevention 367
11.1 Electric and Drug Conversion 367
11.2 Implantable Defibrillator 367
11.3 Maze Procedure and Catheter Ablation 367
11.4 Pacemaker 367
11.5 Prevention of Recurrent AF 367
11.6 New-Onset Atrial Fibrillation 367
11.7 Rate Control 368
11.8 Prevention of Thromboembolism 368
11.9 Drug Rate Control versus Electroconversion 368
11.10 Final Remarks 369
References 369
Chapter 22
Sick Sinus Syndrome (and Carotid Sinus Syndrome) 379
1 Characteristics 379
1.1 Sinus Bradycardia 379
1.2 Sinus Standstill/Arrest 379
1.3 Exit Block or SinoatrialBlock 379
1.4 Bradycardia-Tachycardia Variant 379
1.5 AV Node and Bundle Branches 380
2 Clinical Significance 380
3 Prognosis and Complications 380
4 Therapy 380
5 Prevalence and Etiology 380
6 Pseudo versus True Sick Sinus Syndrome 381
6.1 Influence of Drugs 381
6.2 Abnormal Vagal Reaction After Invasive Procedures
381
6.3 Excessive Sinus Bradycardia in Athletes 381
6.4 Atrial Premature Beats with AV Block 381
6.5 `Laboratory' Sick Sinus Syndrome 382
6.6 Sinus Nodal Re-entry Tachycardia 382
7 Hypersensitive Carotid Sinus Syndrome 382
7.1 Cardioinhibitory Type 382
7.2 Vasodepressor Type 382
8 Symptoms and Complications 382
9 Electrophysiologic Testing 382
1o Therapy 382
References 383
Chapter 23
Atrioventricular Junctional Tachycardias 391
1 Conduction in Sinus Rhythm 391
Conduction in AVNRT 391
3 Common Form of AVNRT 392
4 Rare Form of AVNRT 392
5 Differential Diagnosis 393
5.1 AtrialFlutter 393
5.2 AV Reentry Tachycardia in the WPW Syndrome 393
5.3 Aberration 393
6 Symptoms of AVNRT (Common Form) 393
7 Clinical Significance of AVNRT (Common Form) 393
8 Etiology and Prevalence 394
9 Special Types of AV Junctional Tachycardias 394
9.1 Accelerated AV Junctional Rhythm 394
9.2 Automatic Junctional Tachycardia (AJT) 394
9.3 Permanent Junctional Reciprocating Tachycardia (PJRT)
394
10 Prognosis 395
11 Therapy of AVNRT (Common Form) 395
12 Therapy of the Other Types of AV Junctional
Tachycardias 395
References 395
Chapter 24
The Wolff-Parkinson-White Syndrome 405
1 Pre-Excitation Pattern (WPW Pattern) 405
1.1 Nomenclature 405
1.2 ECG Patterns in Pre-Excitation 406
1.3 Differential Diagnosis of the WPW Pattern 406
1.3.1 Myocardial Infarction 406
1.3.2 Left Ventricular Hypertrophy 406
1.3.3 Pseudo-Delta Wave 406
2 Tachycardias in the WPW Syndrome 406
2.1 Reentry Tachycardias 406
2.2 Atrial Fibrillation and Atrial Flutter in the WPW
Syndrome 407
2.3 Therapy 408
2.4 Therapeutic Pitfalls 408
3 Etiology 408
4 Anatomy and Localization of Accessory Pathways 409
4.1 Algorithms 409
5 Degree of Pre-Excitation, Latent Pre-Excitation and
Concealed Accessory Pathway 410
6 Repolarization Abnormalities 411
7 Differential Diagnosis 411
8 Tachyarrhythmias Associated with the
Wolff-Parkinson-White Syndrome 411
8.1 Atrioventricular Reentry Tachycardia 412
8.2 Other Tachycardias Associated with an Accessory
Pathway 413
8.2.1 Special Condition: Atrial Fibrillation 413
8.3 Ventricular Fibrillation and Sudden Death 413
9 Other Accessory Connections 413
9.1 Mahaim Fibre and Mahaim Tachycardias 413
9.2 Lown-Ganong-Levine Syndrome 414
1o Therapy of the WPW Syndrome 414
1o.1 Acute Termination of Tachycardia 414
10.2 Chronic Therapy for Prevention 415
10.3 Treatment of Patients with an Asymptomatic WPW
Pattern 415
References 416
Chapter 25
Ventricular Premature Beats 435
1 Definition and Nomenclature 435
1.1 Coupling Interval 435
1.2 Compensatory Pause 435
1.3 Morphology and Origin 435
1.4 Special Types 436
1.4.1 R-on-T Phenomenon 436
1.4.2 Interponated VPBs 436
1.4.3 Fusion Beat 436
1.4.4 Concealed Bigeminy 436
2 Differential Diagnosis 436
3 Mechanism 436
4 Prognosis 436
5 Therapy 437
References 437
Chapter 26
Ventricular Tachycardia 445
1 Definition and Characteristics of Ventricular Tachycardia
445
2 Types of Ventricular Tachycardia 445
2.1 Monomorphic VT 445
2.1.1 Etiology of Monomorphic VT 446
2.2 Polymorphic VT of Type `Torsade de Pointes' 446
2.2.1 Etiology of Torsade de Pointes VT 446
2.3 Polymorphic VT (without `Torsade de Pointes') 446
3 A Special Condition: Accelerated Idioventricular Rhythm
446
4 Differential Diagnosis of `Wide QRS' Tachycardias: VT
versus SVT with Aberration 446
4.1 Types of SVT with Aberration (SVT with Wide QRS)
447
4.1.1 SVTab with Bundle-Branch Block 447
4.1.2 SVTab in Wolff-Parkinson-White Syndrome 447
4.1.3 SVT with other Aberrations 447
4.2 Criteria for Differentiation Between VT and SVTab 447
4.3 Criteria for Differentiation Between VT and Artifacts
447
5 Therapy 447
6 Pathophysiology 448
6.1 Reentry 448
6.2 Enhanced Automaticity 448
6.3 Triggered Activity 449
6.4 Electrotonus 449
6.5 Onset of VT 449
7 Types of Ventricular Tachycardia 449
7.1 Monomorphic VT 449
7.2 VT of the Type Torsade de Pointes 449
7.3 Polymorphic VT Without Torsade de Pointes 450
7.4 Special Types of VT 450
7.4.1 Parasystolic VT 450
7.4.2 Bidirectional VT 450
7.4.3 Double Tachycardia 450
7.4.4 Accelerated Idioventricular Rhythm 450
8 Differential Diagnosis of Regular Monomorphic `Wide
QRS Complex' Tachycardias: VT versus SVT with
Aberration 451
8.1 General Remarks 451
8.1.1 Age and Prevalence 451
8.1.2 Underlying Cardiac Disease 451
9 Electrocardiographic Findings in Monomorphic VT 451
9.1 General Findings 451
9.1.1 AV Dissociation 451
9.1.2 Fusion Beats and (Ventricular) Capture Beats 451
9.1.3. VA Block 2° 451
9.1.4 Rate 451
9.1.5 Regularity 452
9.1.6 Comparison of `Wide QRS' Tachycardia ECG with a
Previous ECG Without Tachycardia 452
9.2 QRS Criteria 452
9.2.1 QRS Duration 452
9.2.2 Frontal QRS Axis 452
9.2.3 Morphologic QRS Criteria 452
to Misdiagnoses of Wide QRS Tachycardias 454
10.1 VT Misdiagnosed as SVTab 454
10.2 Differentiation Between Wide Complex Tachycardias
(especially VT) and Artifacts 454
11 Final General (and Therapeutic) Considerations 455
References 456
Section IV Special Topics
Chapter 27
Exercise ECG 479
Information from the Exercise Test 479
1 Indications and Contraindications 479
1.1 Indications 479
1.2 Contraindications 480
2 Limitations 480
3 Methods 480
3.1 Exercise Limited by Symptoms 481
3.2 Heart Rate 481
3.3 Blood Pressure 481
3.4 Double Product 481
3.5 Workload and Exercise Capacity 482
3.6 Duration of Exercise 482
3.7 Stepwise Exercise versus the Ramp Protocol 482
3.8 Criteria for Interruption of the Test 482
4 Procedure 482
4.1 Exercise Preparation 482
4.2 Exercise Procedure 483
5 Validation 483
5.1 Ischemic Response 483
5.1.1 ST Segment 483
5.1.2 T Wave 484
5.1.3 Q Wave 484
5.2 Arrhythmias and Conduction Disturbances 484
5.3 Pitfalls 485
6 Complications 485
6.1 Severe Cardiac Complications 485
6.2 Severe Noncardiac Complications 486
6.3 Common Nonsevere Complications 486
6.4 Rare Nonsevere Complications 486
7 Specificity and Sensitivity 486
8 Exercise in Pre-existing Bundle-Branch Block and Left
Anterior Fascicular Block 487
9 New Bundle-Branch Block During Exercise 487
10 Ventricular Premature Beats During Exercise 487
11 Alterations of QRS During Exercise, Without
Intraventricular Conduction Disturbances 487
12 Right Precordial Leads in the Exercise Test 487
13 Exercise Test After Aortocoronary Revascularization 488
14 Exercise ECG After PTCA 488
15 Exercise Training in Cardiac Rehabilitation After MI and
Revascularization 488
16 Exercise Training in Heart Failure 488
17 Prognostic Impact of the Exercise Test 488
References 489
Chapter 28
Pacemaker ECG 505
1 Single-chamber Pacemaker 505
2 Dual-chamber Pacemaker 506
3 Electric Complications and Failures 506
3.1 Undersensing and Oversensing 5o6
3.2 Lead Fracture and Lead Insulation Damage 507
4 Pacemaker Codes 507
5 Morphologic Features 5o8
6 Pacemaker-Mediated Arrhythmia 508
7 Pacemaker Malfunction 509
7.1 Battery Depletion 509
7.2 Electrode Problems 509
7.3 Oversensing and Undersensing 509
8 Pacemaker Syndrome 509
8.1 Prevalence 509
8.2 Condition 509
8.3 Pathophysiologic Mechanisms 510
9 Indications for Pacing 510
9.1 Pacing in Hypertrophic Obstructive Cardiomyopathy 510
9.2 Pacing in Heart Failure 511
10 Prognosis of AV Sequential (Physiologic) Pacing vs
Single-Chamber Ventricular Pacing 511
10.1 Conclusions 512
References 512
Chapter 29
Congenital and Acquired (Valvular) Heart Diseases 525
1 Congenital Heart Diseases 525
1.1 Atrial Septal Defect of the Ostium Secundum Type 525
1.1.1 Differential Diagnosis 525
1.2 Atrial Septal Defect of the Ostium Primum Type 526
1.3 Valvular Pulmonary Stenosis 526
1.4 Tetralogy of Fallot 526
1.5 Ventricular Septal Defect 526
2 Acquired Valvular Diseases 526
3 Congenital Heart Diseases 526
3.1 Ductus Arteriosus Botalli 526
3.2 Eisenmenger Syndrome 526
3.3 Transposition of the Great Arteries 527
3.4 Situs Inversus 527
3.5 Ebstein's Anomaly 527
3.6 Complex Congenital Cardiac Diseases 527
3.7 Mitral Valve Prolapse (Barlow's Disease) 527
3.8 Hypertrophic Obstructive Cardiomyopathy (HOCM) 527
4 Acquired Valvular Heart Diseases 527
4.1 Valvular Aortic Stenosis 527
4.2 Valvular Aortic Incompetence 527
4.3 Mitral Stenosis 527
4.4 Mitral Incompetence 528
References 528
Chapter 30
Digitalis Intoxication 535
1 Extracardiac Symptoms 535
2 Electrophysiology and Pharmacokinetics 536
3 Acute Digitalis Intoxication and its Therapy 536
References 537
Chapter 31
Special ECG Waves, Signs and Phenomena 541
1 Ashman Phenomenon 541
2 Brugada Sign or Syndrome 541
3 Cabrera Sign 542
4 Chatterjee Phenomenon 542
5 Delta Wave 542
6 Dressler Beat 543
7 Early Repolarization 543
8 Epsilon Wave 543
9 McGee Index 543
10 McGinn White Pattern (SI/Q1I1 Type) 543
11 Katz-Wachtel Sign 543
12 Nadir Sign 543
13 Osborn Wave 543
14 Pardee Q Wave 543
15 R-on-T Phenomenon 544
16 Shallows Sign 545
17 Stork Leg Sign 545
Final Comment 545
References 545
Chapter 32
Rare ECGs 561
Multifocal or Chaotic Atrial Rhythm 561
Absent Pericardium 562
Right Ventricular Dysplasia (Arrhythmogenic Right
Ventricular Cardiomyopathy) 562
Severe Hypertrophic Cardiomyopathy 563
Strange R Wave in Lead V2 in a Patient with Severe
Hypertrophic Cardiomyopathy 564
Strange R Wave in Lead V1 in a Patient without Right
Ventricular Hypertrophy or Posterior Infarction 565
What is the Rhythm? 565
After Left Pneumectomy 568
After Right Pneumectomy 568
Pneumothorax 569
Electrical Alternans 570
Common and Rare False Poling of the Limb Leads (Lead
Displacement) in Frontal QRS Left Axis and in Frontal QRS
Vertical Axis 570
Situs Inversus 573
Epileptic Attack of the ECG Machine 575
Parasystole 575
Left Pleural Effusion 576
So-Called Postsyncopal Bradycardia Syndrome 576
`Dying Heart' 578
Two p Waves: Highly Specific for a Transplanted Heart 579
Pseudo-p Waves in Precordial Leads V3/V4 580
`Double Ventricular Repolarization' 581
T Wave without QRS Complex 581
Double Ventricular Response to a Single Atrial Impulse.
Another Artifact? 582
Another Rare ECG 583
References 584
Subject Index 585
ECG Index 607
