The Only EKG Book You'll Ever Need EIGHTH EDITION Malcolm S. Thaler, M.D. Physician, Internal Medicine, One Medical Group Clinical Instructor in Medicine, Weill Cornell Medical College Medical Staff, New York Presbyterian Hospital New York, New York Executive Editor: Rebecca Gaertner Senior Product Development Editor: Kristina Oberle Production Project Manager: Bridgett Dougherty Marketing Manager: Stephanie Manzo Design Coordinator: Elaine Kasmer Senior Manufacturing Coordinator: Beth Welsh Prepress Vendor: SPi Global 8th edition Copyright © 2015 Wolters Kluwer © 1988 by Lippincott Williams & Wilkins; © 1995 by J.B. Lippincott; © 1999, 2002, 2007, 2010, 2012 by Lippincott Williams & Wilkins All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer Health at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China Library of Congress Cataloging-in-Publication Data Thaler, Malcolm S., author. The only EKG book you'll ever need / Malcolm S. Thaler. — Eighth edition. p. ; cm. Includes index. ISBN 978-1-4511-9394-7 I. Title. [DNLM:1. Electrocardiography.2. Case Reports.3. Heart Diseases—diagnosis. WG 140] RC683.5.E5 616.1'207547—dc23 2014035785 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals' examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer's package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contradictions, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. LWW.com Dedication To Nancy, Ali, and Jon with love, and to everyone who tries to make the lives of others just a little bit better Preface More than 25 years have passed since the first edition of this little book, and our devotion to the principles outlined in the very first pages of that very first book remains just as strong today as ever: 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. So now you hold in your hands the eighth edition of this book, and once again we have tried to make it even better than the ones that came before. We've added material where new developments call for it, shortened and simplified whenever possible, and continued to make sure that everything is discussed in its proper clinical context by putting you right in the middle of real life clinical situations. Very special thanks to Dr. Felix Yang, M.D., Associate Director of Cardiac Electrophysiology at Maimonides Medical Center in New York City, whose impeccable commentary and insightful edits went way beyond the extraordinary and ensure that you will be reading the most up-to-date, clear and accurate text that anyone could hope for. Special thanks as always to the wonderful folks at Lippincott Williams & Wilkins who always manage to produce the most attractive, most readable EKG book one could ever hope for. And a particularly special tip of the hat to Kristina Oberle and Rebecca Gaertner of making this process such a civilized pleasure. For those of you who are picking up this book for the first time—as well as those of you who are making a return visit—I hope The Only EKG Book You Will Ever Need will provide you with everything you need to read EKGs quickly and accurately. Malcolm 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 Coming Attractions Chapter 2 Hypertrophy and Enlargement of the Heart 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 PSVT With Aberrancy Programmed Electrical Stimulation 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 Syndrome Lown–Ganong–Levine Syndrome Associated Arrhythmias Summary: Preexcitation Case 9 Chapter 6 Myocardial Ischemia and Infarction What Is a Myocardial Infarction? How to Diagnose a Myocardial Infarction Summary: The EKG Changes of an Evolving Myocardial Infarction Localizing the Infarct Non–Q-Wave Myocardial Infarctions Apical Ballooning Syndrome Angina Summary: The ST Segment in Ischemic Cardiac Disease Limitations of the EKG in Diagnosing an Infarction Stress Testing Case 10 Case 11 Chapter 7 Finishing Touches Electrolyte Disturbances Hypothermia Drugs More on the QT Interval Other Cardiac Disorders Pulmonary Disorders Central Nervous System Disease Sudden Cardiac Death The Athlete's Heart Preparticipation Screening for Athletes Sleep Disorders The Preoperative Evaluation Summary: Miscellaneous Conditions Case 12 Case 13 Chapter 8 Putting It All Together The 11-Step Method for Reading EKGs Review Charts Chapter 9 1 How Do You Get to Carnegie Hall? Index Getting Started In this chapter you will learn: 1 not a thing, but don't worry. There is plenty to come. Here is your chance to turn a few pages, take a deep breath or two, and get yourself settled and ready to roll. Relax. Pour some tea. Begin. On the opposite page is a normal electrocardiogram, or EKG. By the time you have finished this book—and it won't take very much time at all—you will be able to recognize a normal EKG almost instantly. Perhaps even more importantly, you will have learned to spot all of the common abnormalities that can occur on an EKG, and you will be good at it!