Marriott's Practical Electrocardiography

iv
Contents
Digital Contents: Quizzes, Animations and Videos List x
Contributors xii
Preface xvi
SECTION I: BASIC CONCEPTS
CHAPTER 1 CARDIAC ELECTRICAL ACTIVITY 1
Tobin H. Lim and David G. Strauss
The Book: Marriott’s Practical Electrocardiography , 13th Edition 2
The Electrocardiogram 3
Anatomic Orientation of the Heart 4
The Cardiac Cycle 6
Cardiac Impulse Formation and Conduction 10
Recording Long-Axis (Base-Apex) Cardiac Electrical Activity 12
Recording Short-Axis (Left Versus Right) Cardiac Electrical Activity 17
CHAPTER 2 RECORDING THE ELECTROCARDIOGRAM 23
David G. Strauss, Tobin H. Lim, and Douglas D. Schocken
The Standard 12-Lead Electrocardiogram 24
Correct and Incorrect Electrode Placements 31
Alternative Displays of the 12 Standard Electrocardiogram Leads 34
Alternative Electrode Placement 40
Other Practical Points for Recording the Electrocardiogram 41
CHAPTER 3 INTERPRETATION OF THE NORMAL
ELECTROCARDIOGRAM 45
David G. Strauss, Tobin H. Lim, and Douglas D. Schocken
Electrocardiographic Features 46
Rate and Regularity 48
P-wave Morphology 50
The PR Interval 51
Morphology of the QRS Complex 52
Morphology of the ST Segment 59
T-wave Morphology 61
U-wave Morphology 63
QT and QTc Intervals 64 Contents v
Cardiac Rhythm 65
A Final Word 69


eChapter I: INTERPRETATION OF THE
ELECTROCARDIOGRAM IN 3D
Charles W. Olson, E. Harvey Estes Jr, Vivian P. Kamphuis,
Esben Andreas Carlsen, David G. Strauss, and Galen S. Wagner (deceased)
SECTION II: CHAMBER ENLARGEMENT AND
CONDUCTION ABNORMALITIES
CHAPTER 4 CHAMBER ENLARGEMENT 73
Douglas D. Schocken, Ljuba Bacharova, and David G. Strauss
Atrial Enlargement 75
Electrocardiogram Pattern With Atrial Enlargement 78
Ventricular Enlargement 80
Electrocardiogram QRS Changes With Ventricular Enlargement 82
Left-Ventricular Dilation 83
Left-Ventricular Hypertrophy 85
Electrocardiogram Pattern With Left-Ventricular Hypertrophy 86
Right-Ventricular Hypertrophy 90
Biventricular Hypertrophy 95
Scoring Systems for Assessing LVH and RVH 97
CHAPTER 5 INTRAVENTRICULAR CONDUCTION
ABNORMALITIES 101
David G. Strauss and Tobin H. Lim
Normal Conduction 102
Bundle-Branch and Fascicular Blocks 103
Unifascicular Blocks 107
Bifascicular Blocks 115
Systematic Approach to the Analysis of Bundle-Branch and
Fascicular Blocks 124
Clinical Perspective on Intraventricular-Conduction Disturbances 127
SECTION III: ISCHEMIA AND INFARCTION
CHAPTER 6 INTRODUCTION TO MYOCARDIAL ISCHEMIA
AND INFARCTION 135
David G. Strauss, Douglas D. Schocken, and Tobin H. Lim
Introduction to Ischemia and Infarction 136
Electrocardiographic Changes 140 vi Contents
CHAPTER 7 SUBENDOCARDIAL ISCHEMIA FROM
INCREASED MYOCARDIAL DEMAND 149
David G. Strauss and Tobin H. Lim
Changes in the ST Segment 150
CHAPTER 8 TRANSMURAL MYOCARDIAL ISCHEMIA
FROM INSUFFICIENT BLOOD SUPPLY 163
David G. Strauss and Tobin H. Lim
Changes in the ST Segment 164
Changes in the T Wave 175
Changes in the QRS Complex 176


TRANSMURAL MYOCARDIAL ISCHEMIA
FROM INSUFFICIENT BLOOD SUPPLY:
ONLINE SUPPLEMENT
David G. Strauss and Tobin H. Lim
Estimating Extent, Acuteness, and Severity of Ischemia
CHAPTER 9 MYOCARDIAL INFARCTION 181
David G. Strauss and Tobin H. Lim
Infarcting Phase 182
Chronic Phase 189


MYOCARDIAL INFARCTION:
ONLINE SUPPLEMENT
David G. Strauss and Tobin H. Lim
Estimating Infarct Size and Infarcts in the Presence of
Conduction Abnormalities
Myocardial Infarction and Scar in the Presence of
Conduction Abnormalities
SECTION IV: DRUGS, ELECTROLYTES, AND
MISCELLANEOUS CONDITIONS
CHAPTER 10 ELECTROLYTES AND DRUGS 203
Robbert Zusterzeel, Jose Vicente Ruiz, and David G. Strauss
Cardiac Action Potential 204
Electrolyte Abnormalities 206
Drug Effects 212
CHAPTER 11 MISCELLANEOUS CONDITIONS 223
Douglas D. Schocken, Tobin H. Lim, and David G. Strauss
Introduction 224
Cardiomyopathies 224 Contents vii
Pericardial Abnormalities 228
Pulmonary Abnormalities 232
Intracranial Hemorrhage 237
Endocrine and Metabolic Abnormalities 238
CHAPTER 12 CONGENITAL HEART DISEASE 245
Sarah A. Goldstein and Richard A. Krasuski
Atrial Septal Defects 246
Ventricular Septal Defect 251
Patent Ductus Arteriosus 253
Pulmonary Stenosis 253
Aortic Stenosis 253
Coarctation of the Aorta 253
Tetralogy of Fallot 254
Ebstein Anomaly 255
Congenitally Corrected Transposition of the Great Arteries 256
Complete Transposition of the Great Arteries 257
Fontan Circulation 258
SECTION V: ABNORMAL RHYTHMS
CHAPTER 13 INTRODUCTION TO ARRHYTHMIAS 263
Zak Loring, David G. Strauss, Douglas D. Schocken,
and James P. Daubert
Introduction to Arrhythmia Diagnosis 264
Problems of Automaticity 265
Problems of Impulse Conduction: Reentry 268
Approach to Arrhythmia Diagnosis 272
Clinical Methods for Detecting Arrhythmias 280
Ambulatory Electrocardiogram Monitoring 281
Invasive Methods of Recording the Electrocardiogram 286
CHAPTER 14 PREMATURE BEATS 293
James P. Daubert, Aimée Elise Hiltbold, and Fredrik Holmqvist
Premature Beat Terminology 294
Differential Diagnosis of Wide Premature Beats 297
Mechanisms of Production of Premature Beats 298
Atrial Premature Beats 299
Junctional Premature Beats 304
Ventricular Premature Beats 307
Right-Ventricular Versus Left-Ventricular Premature Beats 312
Multiform Ventricular Premature Beats 315
Groups of Ventricular Premature Beats 316
Vulnerable Period and R-on-T Phenomenon 317
Prognostic Implications of Ventricular Premature Beats 317viii Contents
CHAPTER 15 SUPRAVENTRICULAR TACHYARRHYTHMIAS 321
Kevin P. Jackson and James P. Daubert
Introduction 322
Differential Diagnosis of Supraventricular Tachycardia 324
Sinus Tachycardia 329
Atrial Tachycardia 331
Junctional Tachycardia 334
Atrioventricular Nodal Reentrant Tachycardia 335
Accessory Pathway Mediated Tachycardia 338
CHAPTER 16 ATRIAL FIBRILLATION AND FLUTTER 345
Jonathan P. Piccini, James P. Daubert, and Tristram D. Bahnson
Pathophysiology of Atrial Fibrillation and Atrial Flutter 346
Twelve-Lead Electrocardiographic Characteristics of Atrial Fibrillation 350
Atrial Flutter 355
Twelve-Lead Electrocardiographic Characteristics of
Atypical Atrial Flutter 358
Clinical Considerations of Atrial Fibrillation and Atrial Flutter 364
CHAPTER 17 VENTRICULAR ARRHYTHMIAS 369
Albert Y. Sun and Jason Koontz
Definitions of Ventricular Arrhythmias 370
Etiologies and Mechanisms 370
Diagnosis 371
CHAPTER 18 BRADYARRHYTHMIAS 391
Larry R. Jackson II, Camille Genise Frazier-Mills, Francis E. Ugowe,
and James P. Daubert
Mechanisms of Bradyarrhythmias: Decreased Automaticity 393
Atrioventricular Conduction Disease 400
Severity of Atrioventricular Block 400
Location of Atrioventricular Block 410
Atrioventricular Nodal Block 411
Infranodal (Purkinje) Block 414
CHAPTER 19 VENTRICULAR PREEXCITATION 421
Donald D. Hegland, Stephen Gaeta, and James P. Daubert
Clinical Perspective 423
Pathophysiology 426
Electrocardiographic Diagnosis of Ventricular Preexcitation 430
Ventricular Preexcitation as a “Great Mimic” of Other
Cardiac Problems 434
Electrocardiographic Localization of the Pathway of
Ventricular Preexcitation 435
Ablation of Accessory Pathways 438 Contents ix
CHAPTER 20 INHERITED ARRHYTHMIA DISORDERS 445
John Symons and Albert Y. Sun
The Long QT Syndrome (LQTS) 446
LQTS Electrocardiographic Characteristics 446
Electrocardiogram as Used in Diagnosis for LQTS 448
The Short QT Syndrome (SQTS) 449
SQTS Electrocardiographic Characteristics 449
Electrocardiogram as Used in Diagnosis for SQTS 451
The Brugada Syndrome 452
Arrhythmogenic Right-Ventricular Cardiomyopathy/Dysplasia 454
J-wave Syndrome 458
Catecholaminergic Polymorphic Ventricular Tachycardia 460
CHAPTER 21 IMPLANTABLE CARDIAC PACEMAKERS 465
Brett D. Atwater and Daniel J. Friedman
Basic Concepts of the Implantable Cardiac Pacemaker 466
Pacemaker Modes and Dual-Chamber Pacing 472
Pacemaker Evaluation 478
Myocardial Location of the Pacing Electrodes 482
Special Algorithms to Avoid Right-Ventricular Pacing 484
Cardiac Resynchronization Therapy 485
Index 493