Twelve-Lead Electrocardiography: Theory and Interpretation

175 Pages·2007·9.076 MB·English

by  D. Bruce Foster DO (auth.)

Twelve-Lead Electrocardiography
Second Edition
D. Bruce Foster
Twelve-Lead
Electrocardiography
Theory and Interpretation
Second Edition
D.Bruce Foster,DO
Department ofEmergency Medicine
Waynesboro Hospital
and
Pennsylvania Institute ofApplied Health Sciences
Waynesboro,PA,17268
USA
British Library Cataloguing in Publication Data
Foster,D.Bruce,1945–
Twelve-lead electrocardiography :theory and
interpretation.– 2nd ed.
1. Electrocardiography
I. Title II. Foster,D.Bruce,1945–.Twelve-lead
electrocardiography for ACLS providers
616.1′2′07547
ISBN-13:9781846285929
ISBN-10:1846285925
Library ofCongress Control Number:2006932407
ISBN-10:1-84628-592-5 e-ISBN-10:1-84628-610-7
ISBN-13:978-1-84628-592-9 e-ISBN-13:978-1-84628-610-0
Printed on acid-free paper
© Springer-Verlag London Limited 2007
Originally Published as Twelve-Lead Electrocardiography for ACLS Providers,WB Saunders,Co.,
1996.ISBN 0721658733.
Apart from any fair dealing for the purposes ofresearch or private study,or criticism or review,
as permitted under the Copyright,Designs and Patents Act 1988,this publication may only be
reproduced,stored or transmitted,in any form or by any means,with the prior permission in
writing ofthe publishers,or in the case ofreprographic reproduction in accordance with the
terms oflicences issued by the Copyright Licensing Agency.Enquiries concerning reproduction
outside those terms should be sent to the publishers.
The use ofregistered names,trademarks,etc.in this publication does not imply,even in the
absence ofa specific statement,that such names are exempt from the relevant laws and regula-
tions and therefore free for general use.
Product liability:The publisher can give no guarantee for information about drug dosage and
application thereofcontained in this book.In every individual case the respective user must
check its accuracy by consulting other pharmaceutical literature.
9 8 7 6 5 4 3 2 1
Springer Science+Business Media
springer.com
To those delightful little souls who daily make me smile:
Mckenzie,Lleyton,Alexa,and Olivia.
Foreword
Ifyou are a cardiologist or have a photographic memory,you may not need
Dr.Foster’s new book.But,for the rest ofus on the front lines ofemergency
care,it is a valuable resource that you will want to have by your side at work.
I have had the first edition of this book by my station in the emergency
department for ten years now.I use it everyday for teaching house staffand
often turn to it for reference myself.
For those ofus without perfect memories,Dr.Foster’s clinical approach is
ideal.He has the knack of making the complex simple.He does not expect
the reader to memorize every squiggle on the page; instead he inspires
understanding by giving readers the tools they need to comprehend why
ECGs look the way they do.When a resident comes to me with an ECG,I do
not have to spend ten minutes delivering a confusing explanation.I just open
Dr.Foster’s book to the right page and hand it to the resident for review.
The book is organized so that you can turn to the relevant chapter and
instantly know what the differential diagnosis might be.His selection ofcase
studies covers the vast majority ofthe ECGs you will be called on to read in
any sort of emergent situation;anything else can wait for the cardiologist.
This second edition features some extensively revised new chapters that
make it even more useful than the first.Three very clinical chapters,in par-
ticular,offer a roadmap to your daily practice.Chapter 9 gives an excellent
summary ofthe pitfalls that can plague a physician in diagnosing infarctions.
Chapter 10 provides a concise,coherent review of anginal syndromes that
makes it possible for the novice to catch on quickly.And the case presenta-
tions in Chapter 14 offer a spectrum of fascinating real-life clinical scenar-
ios that help you to integrate the ECG into daily clinical practice and
structure your approach to acute coronary syndromes.They also serve to
show us all why an ECG is but one ofthe many clues that must ultimately be
synthesized into an accurate diagnosis.
Mark L.Feldman,MD
Supervising Physician
Emergency Department
Whangarei Base Hospital
Whangarei,New Zealand
vii
Preface
Ten years have passed since Twelve Lead Electrocardiography for ACLS
Providerswas written in response to a need for a clear,concise,introductory
level text on the morphologic interpretation of electrocardiograms. This
need has grown more compelling in the last decade, as a multiplicity of
efficacious therapeutic interventions has made the early recognition ofacute
coronary syndromes ever more important.The text was developed primar-
ily for physicians, physicians’ assistants, nurses, and paramedics who are
advanced cardiac life support (ACLS) certified and are already familiar with
cardiac dysrhythmias.Therefore,the text deals solely with morphology and
does not discuss dysrhythmias.
The need for the first edition was initially spurred by the revolutionary
development in the 1980s of thrombolytic therapy for acute myocardial
infarction (AMI),and,subsequently,the evolution ofpercutaneous coronary
intervention.The availability of these tools,and their time dependency,has
magnified the critical role offirst responders and primary care providers in
the early recognition and treatment ofAMI.
The clinical chapters in this second edition have been extensively rewrit-
ten to reflect new concepts in the clinical classification ofpatients with chest
pain,including acute coronary syndrome,and ST and non–ST-segment ele-
vation myocardial infarction.Sections have been added on the diagnosis of
AMI in patients with bundle branch block (BBB),and the case presentations
have been expanded and updated to better reflect contemporary practice.
Additional illustrations and new references have been incorporated.
I have tried to include all ofthe pertinent information that ACLS providers
working in EMS systems,primary care centers,emergency departments,and
critical care units will need to know to implement chest pain evaluation pro-
tocols and,hopefully,to speed coronary intervention.
In reality,however,the text has proven to be equally valuable to medical
students and non-critical care physicians who need a working knowledge of
the important fundamentals of morphologic electrocardiography,but who
need not become professional electrocardiographers.Thus,the text empha-
sizes simplicity,clinically useful concepts,and common clinical parlance.It
is written in a conversational tone,and is not intended to serve as a refer-
ence text for serious postgraduate students of electrocardiography.
ix
x Preface
Nevertheless,fundamental electrophysiologic principles are emphasized
to the extent that students have the opportunity to deduce patterns created
by both physiologic and pathologic processes,rather than relying on memo-
rizing electrocardiographic (ECG) patterns of disease.I have tried to com-
municate the sense ofjoy that comes from deduction and understanding,as
opposed to the drudgery of memorization.
There are many people who played an important role in the writing ofthis
text,primary among whom are the many students who have instructed me
in what works and what doesn’t over 15 years of teaching electrocardiogra-
phy.This second edition is my thanks for the joy they have shared with me
in learning.
And finally,special thanks go,again,to Lauren Datcher,R.N.,whose eagle
eyes never fail to defect virtually every one of my ubiquitous manuscript
errors.
D.Bruce Foster,DO
Contents
Foreword by Mark L.Feldman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
1 Essential Cardiac Anatomy and Physiology as It Relates
to the Electrocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Electrocardiographic Waveforms . . . . . . . . . . . . . . . . . . . . . . . . 5
3 Cardiac Vectors and Lead Systems . . . . . . . . . . . . . . . . . . . . . . . 12
4 Derivation of the Normal Electrocardiogram . . . . . . . . . . . . . . . 17
5 Electrical Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
6 Intraventricular Conduction Delays:The Hemiblocks . . . . . . . . 34
7 Intraventricular Conduction Delays:The Bundle Branch Blocks 42
8 Chamber Enlargement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
9 Myocardial Infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
10 Ischemia and Anginal Syndromes . . . . . . . . . . . . . . . . . . . . . . . . 84
11 The Electrocardiogram and the Clinical Evaluation of
Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
12 The Advanced Cardiac Life Support Provider and Therapeutic
Interventions in Acute Myocardial Infarction . . . . . . . . . . . . . . . 101
13 Miscellaneous Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
14 Case Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
xi
1
Essential Cardiac Anatomy and Physiology
as It Relates to the Electrocardiogram
Developing the capability of interpreting a 12-lead electrocardiogram
depends upon an understanding ofa few fundamental principles ofanatomy
and physiology.In this chapter,I will review the electrical conduction system
of the heart and the methods that are used to record depolarization.
The Specialized Cardiac Conduction System
In the normal heart during sinus rhythm,impulse formation is initiated in
the sinoatrial (SA) node(Figure 1.1),and then spreads as a wave ofdepolar-
ization over the atria until it reaches the atrioventricular (AV) node,which is
near the junction of the interatrial and interventricular septa.
The AV node represents the sole pathway for conducting the impulse from
the atria to the ventricles,except when it is bypassed by abnormal congeni-
tal pathways.Its unique purpose is to slow the rate ofimpulse conduction to
give the atria time to finish emptying of blood and the ventricles time to
finish filling with blood.This is necessary because mechanical contraction
of cardiac muscle is normally slower than the rapid process of electrical
depolarization (Figure 1.2).
The common bundle of Hisnext conducts the impulse through the supe-
rior ventricular septum and then quickly divides into the right and left
bundle branch(Figure 1.1).Perhaps because the left ventricle is bigger than
the right ventricle,the left bundle splits into two hemibundles,one running
anteriorly and superiorly out of the page toward the reader,and the other
running posteriorly and inferiorly into the page,as ifaway from the reader.
Finally,the bundle branches divide numerous times into Purkinje fibers,
which are the final pathway for conduction of the impulse to ventricular
muscle. Once ventricular muscle is stimulated by the impulse traveling
down the Purkinje fibers, it depolarizes outwardly from endocardium to
epicardium.
Electrical impulses are conducted much more rapidly through the spe-
cialized conduction system ofthe heart described in the previous paragraphs
than through typical cardiac muscle. This allows the electrical impulse to
reach almost all ventricular muscles nearly simultaneously,thus,allowing for
1
2 Chapter 1 Essential Cardiac Anatomy and Physiology as It Relates to the Electrocardiogram
SA Node
Left Bundle Branch
Anterior Fascicle
Bundle of His
AV Node
Right Posterior Fascicle
Bundle
Branch
Purkinje System
Figure 1.1. The specialized cardiac conduction system.
coordinated contraction of the ventricles.There is a small,but important,
difference in the sequence ofactivationofvarious portions ofthe ventricles,
which will be discussed later.
Muscle Mass of Cardiac Chambers
The atriapump blood over only very short distances (across the AV valves
into the ventricles);therefore,they are very thin-walled structures with very
little muscle mass.Conversely,the right ventricle must pump blood all the
way through the lungs,and therefore has a thicker wall and more muscle
mass.Finally,the left ventricle pumps blood out to the entire body,and thus
has the thickest wall ofall the chambers,three to four times thicker than the
wall of the right ventricle (Figure 1.3).
Ventricular
Systole
Atrial
Systole
Left Ventricular
Pressure Curve
ECG
Figure 1.2. Synchronous recording of left ventricular pressure curve and ECG.The time required for
mechanical contraction during atrial and ventricular systole is shown by the left ventricular pressure
curve.Note how these times exceed the times required for atrial and ventricular depolarization (P wave
and QRS duration.)