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Textbook Of Clinical Electrocardiography 2e(pb)2006 by Chugh
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TEXTBOOK OF CLINICAL ELECTROCADIOGRAPHY 3e(pb)2012
Author: S. N. CHUGH
ISBN: 9789350250402
Year: 2012
Publisher: JAYPEE BROTHERS MEDICAL PUBLISHERS PVT LTD.
Category: CARDIOLOGY
Edition: 3
Format: Paperback
Language: English
Pages: 576
 ABOUT THE TITLE
Unique in itself as it covers all the aspects of electrocariography arranged in different chapters and sections. Emphasiezes on the basic concepts of ecg explains the text of ecg with diagrams and figures. This edition is colorful contains new ecgs barring few old ones. These ecgs have been enlarged to make the interpretations clear. Written in simple and easy language having salient features in tables and boxes. Certain topics which are not covered by many other ecg books such as pacemakers, ecg in miscellaneous diseases and arrhythmias have been included to make it a comprehensive textbook.
Author: S N Chugh

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 TABLE OF CONTENTS
SECTION ONE
Physiological Mechanisms Governing
Electrocardiographic Deflections
1. Fundamentals of Electrocardiography ........ 3
• Electrocardiogram—An Introduction ........ .......... 3
• Einthoven Theory of Electrical Activity ........ ....... 4
• Anatomy and Physiology of Conduction Tissues of the Heart ........... 4
• Applied Physiology ........ ............ 5
• Modes of Activation of the Heart (Atria and Ventricles) .......... 5
2. The Electrode and the Lead System........7
• Electrodes ........ ........ 7
• Lead System ........ ......... 7
• Arbitrary Orientation of Different Leads ........ ..... 9
• Continuous Monitoring System Used in Coronary Care Unit (CCU) ........... 10
• Special or Unconventional Leads for Recording Atrial Activity from Back of the Heart ........... 11
3. Action Potentials and Waveforms ......... 12
• Charged or Polarized or Resting Membrane ............ 12
• Generation of Action Potential in Pacemaker Cells ......... 12
• Recording of Depolarization and Repolarization as Waveforms (P-QRS-T Complex) on ECG ............14
• Waveforms of Electrocardiogram........ ...........15
• Atrial Depolarization Wave (Atrial Complex—P wave) ......... 15
• Ventricular Activation Complex (Depolarization) ........ 15
• Intrinsic or Intrinsicoid Deflections ........ ........20
• Physiology of R Wave Progression ........ .........20
4. The Cardiac Vector and the Electrical Axis ........... 23
• Electrical Field of the Heart ........ ......... 23
• Axial Reference Systems ........ ........ 24
• Ventricular Depolarization, Instantaneous QRS Vectors and the Mean Manifest Electrical Axis .........24
• Axis Deviation ........ ............ 29
• Abnormal P wave Axis and Associated Clinical Conditions ........ 36
5. The Electrical Rotation of the Heart ............ 37
• Positions of the Heart ........ ........ 37
• Effect of Deep Respiration on the Rotational Patterns .......... 41
Textbook of Clinical Electrocardiography
xvi
SECTION TWO
The Electrocardiogram
6. Normal Electrocardiogram........ 45
• Electrocardiographic (ECG) Paper ........ .........45
• Heart Rate ........ ........... 46
• Natural Pacemakers and Heart Rates ........ .........47
• Prerequisite for Good Electrocardiogram Recording ............ 48
• Normal Electrocardiogram in Adults ........ ..........49
• Normal Electrocardiographic Intervals ........ .......54
• Normal Segments and Junctions on ECG ........ ...59
• Voltage Measurement ........ ............ 59
• Electrocardiogram in Infants ........ ........ 60
• Electrocardiogram in Children ........ .......... 60
7. Normal Electrocardiographic Variants in Adults ........... 62
• Normal Electrocardiographic Variants in Adults—General Aspects ........... 62
• Conditions Associated with Well Recognized Electrocardiographic Variants ........... 64
SECTION THREE
Chamber Hypertrophy or Enlargement
8. Atrial Hypertrophy/Enlargement ............ 71
• Anatomy and Electrophysiology of Human Heart .......... 71
• Chamber Enlargement ........ ........... 71
• Atrial Hypertrophy and Enlargement ........ .........72
• Left Atrial Hypertrophy or Enlargement ........ ....73
• Combined Right and Left Atrial Hypertrophy (Biatrial Hypertrophy) ........ 77
• Review at Glance ........ ........ 80
9. Ventricular Hypertrophy/Enlargement ........ 82
• Left Ventricular Hypertrophy (LVH) ........ ..........84
• Review at Glance ........ ........ 90
• Right Ventricular Hypertrophy (RVH) ........ .......91
• Biventricular (Combined Right and Left Ventricles) Hypertrophy ........ 95
SECTION FOUR
Conduction Defects
10. Intracardiac Conduction Defects ......... 101
• Basic Concepts of Conduction ........ ......... 103
11. Sinus Node Dysfunction .......... 105
• Sinus Node Dysfunction and Structural Nodal Disease ........ 105
• Sinoatrial Blocks (SA Blocks) ........ ........... 106
• Sick Sinus (Lazy Sinus, Unstable Sinus) Syndrome—The Structural Nodal Disease .......... 107
• Hypersensitive Carotid Sinus Syndrome ........ .. 115
12. Atrioventricular (AV) Blocks............ 116
• Incomplete AV Blocks ........ .......... 116
• Complete (Third Degree) AV Block ........ .......... 121
• Clinical Significance of Second Degree AV Block and Complete AV Block ........ 124
Contents
xvii
• High Grade AV Block ........ ........... 125
• Diagnosing AV Blocks at Glance ........ .......... 126
13. Bundle Branch Blocks ........ 128
• Disorders of Intraventricular Conduction ........ 128
• Bundle Branch Blocks ........ ........... 128
• Right Bundle Branch Block Pattern ........ ........... 130
• Review at a Glance ........ .......... 133
• Right Bundle Branch Block with Left Ventricular Hypertrophy ........... 133
• Intermittent Right Bundle Branch Block ........ ... 133
• Right Bundle Branch Block with Right Ventricular Hypertrophy ........ 134
• Left Bundle Branch Block (LBBB) Pattern ........ . 137
• Left Bundle Branch with Left Anterior Fascicular Block ............ 140
• Left Bundle Branch Block with Left Posterior Fascicular Block........ 142
• Left Bundle Branch Block with Left Ventricular Hypertrophy ........ 142
• Review at Glance ........ ........ 143
• Alternating Right and Left Bundle Branch Block (Intermittent Bilateral Bundle Branch Block) ......... 144
• Masquerading Bundle Branch Block ........ ......... 144
• Bundle Branch Block Alternans ........ ............ 144
• Nonspecific or Indeterminate Intraventricular Conduction Defect ............ 144
14. The Fascicular Blocks or Hemiblocks ............ 146
• Fascicular Blocks ........ ........ 146
• The Left Anterior Fascicular Block (Left Anterior Hemiblock) ........ 147
• Left Anterior Fascicular or Hemiblock (LAH) Block with Left Ventricular Hypertrophy ......... 149
• Left Posterior Fascicular Block or Left Posterior Hemiblock (LPH) ............ 150
• Left Septal Fascicular Block........ ......... 153
• Peri-infarction Block ........ ........ 153
• Review at a Glance ........ .......... 153
• Combined Fascicular Blocks ........ ............ 153
• Bifascicular Blocks ........ ........... 154
• Trifascicular Block ........ ........... 156
15. The SI, SII, SIII Syndrome.......... 158
• Definition ........ .......... 158
• Mechanisms ........ ......... 158
• Etiology ........ ........ 159
SECTION FIVE
Stress Electrocardiography
16. Stress Electrocardiography ............ 163
• Exercise Electrocardiography ........ .......... 163
• Pharmacological Methods of Stress Testing ........... 178
• Pharmacological Methods of Stress Testing ........... 180
SECTION SIX
Continuous Ambulatory Electrocardiographic Recording
17. Continuous Ambulatory Electrocardiographic Recording........ 183
• Continuous Ambulatory (Holter) Monitoring ........ 183
• Superiority of Ambulatory Electrocardiography Over Exercise Testing .......... 187
Textbook of Clinical Electrocardiography
xviii
SECTION SEVEN
Coronary Artery Disease
18. Myocardial Ischemia ........... 193
• Pseudodepression and Pseudoelevation of ST Segment VS True (Ischemic)
ST Depression and Elevation ........ ........... 198
• Acute versus Chronic Change ........ ......... 201
• Angina in a Patient with Infarction ........ ........... 201
• Nonspecific ST Segment and T Wave Changes ........... 201
• Clinical and Electrocardiographic Correlation in Angina Pectoris ........ 204
• Variant Angina (Prinzmetal's Angina) Syndrome ......... 204
• Asymptomatic Electrocardiographic Abnormalities ........... 209
19. Myocardial Infarction .......... 211
• Hyperacute Myocardial Infarction ........ ............ 221
• Evolution of Acute Myocardial Infarction ........ 223
• Subtle, Atypical or Nonspecific Pattern of Infarction.......... 225
• Chronic Established Changes ........ .......... 230
• Localization of Myocardial Infarction by Electrocardiographic Patterns ......... 232
• Infarction of Left Ventricle ........ ........ 232
• Right Ventricular Infarction ........ ........ 249
• Subendocardial Infarction ........ ......... 250
• Interventricular Septal Infarction ........ ......... 251
• Atrial Infarction ........ ........ 251
• ECG Features of Atrial Infarction ........ ......... 252
• Myocardial Infarction with Conduction Disturbance ......... 252
• Ventricular Aneurysm........ .......... 262
SECTION EIGHT
Congenital and Heredofamilial Disorders
20. Congenital Heart Disease......... 267
• Congenital Pulmonary Stenosis with Intact Septum........... 267
• Primary Pulmonary Hypertension ........ ............ 269
• Atrial Septal Defect (ASD) ........ ........ 269
• Atrial Septal Defect with Reversed Shunt—The Eisenmenger's Syndrome ........ 273
• Common Atrium ........ ........ 274
• Ventricular Septal Defect (VSD) ........ ........... 274
• Malposition and Malformation of the Heart ........... 276
• Dextrocardia (True or Mirror Image versus Technical) ......... 277
• Patent Ductus Arteriosus (PDA) ........ ........... 280
• Corrected Transposition of Great Vessels ........ . 282
• Tetralogy of Fallot ........ ............ 284
• Pentalogy of Fallot ........ ........... 286
• Triology of Fallot ........ ......... 286
• Ebstein's Anomaly ........ ........... 287
• Persistent Truncus Arteriosus ........ .......... 288
• Aortopulmonary Communication (Window)......... 289
• Tricuspid Atresia ........ ........ 289
• Congenital Aortic Stenosis ........ ........ 290
Contents
xix
21. Heredofamilial Prolonged Q-T Syndromes.......... 292
• Acquired Prolonged Q-T Syndrome ........ ......... 293
• Clinical Significance ........ ........ 294
22. Accelerated Conduction or Pre-excitation .......... 295
• Wolff-Parkinson-White (WPW) Syndrome ........ 295
• WPW Variants ........ .......... 304
23. Hypertrophic Cardiomyopathy........ 308
• Etiology ........ ........ 308
• Macroscopic Subtypes ........ .......... 309
• The Electrocardiogram ........ ......... 309
• Clinical Significance ........ ........ 313
SECTION NINE
Acquired Heart Disease
24. Rheumatic Heart Disease ......... 317
• Acute Rheumatic Carditis ........ ......... 317
• Chronic Rheumatic Valvular Heart Disease ........... 318
• Floppy Mitral Valve (Mitral Valve Prolapse) Syndrome ............ 327
25. Myocarditis and Cardiomyopathies .......... 330
• Myocarditis ........ .......... 330
• Chagas' Myocarditis ........ ........ 332
• Review At Glance ........ ............ 333
• Cardiomyopathies ........ ........... 333
26. Pericarditis ........ 339
• Pericarditis with Effusion........ .......... 343
• Chronic Constrictive Pericarditis ........ .......... 345
27. Acute Pulmonary Thromboembolism (Acute Cor Pulmonale) ........ 347
• Pathogenesis ........ ......... 347
• Electrocardiographic Manifestations ........ ......... 347
• Electrocardiogram ........ ........... 347
• Frontal Plane Leads (I, II, III, aVR, aVL and aVF) .......... 347
• Horizontal Plane Leads (V1 to V6 ) ........ ........ 348
• Diagnosis and Differential Diagnosis ........ ........ 349
• Review at Glance ........ ........ 351
• ECG Changes in Acute Cor Pulmonale........ ..... 351
28. Chronic Obstructive Pulmonary Disease (COPD) and Chronic Cor Pulmonale .......... 352
• Chronic Cor Pulmonale ........ ........ 352
• Chronic Cor Pulmonale without Obstructive Disease of the Airways ........ 356
29. Systemic Hypertension ............ 360
• Hemodynamic Alterations ........ ........ 360
• Electrocardiogram ........ ........... 360
• Hypertension Associated with Other Conditions .......... 362
• Effect of Treatment ........ .......... 362
Textbook of Clinical Electrocardiography
xx
SECTION TEN
The Disorders of Cardiac Rhythm
30. Basic Physiopathologic Considerations ........ 367
• Anatomy and Physiology of Conduction System........ 367
• Classification of Cardiac Arrhythmias ........ ...... 368
• Basic Approach for Analysis of Cardiac Rhythm........ 369
• Arrhythmogenesis ........ ........... 370
• Other Electrophysiological Abnormalities Leading to Cardiac Arrhythmias .......... 372
• Review at a Glance ........ .......... 375
31. Sinus Rhythm and its Manifestations ........ 376
• Sinus Rhythm........ ............ 376
• Sinus Arrhythmia ........ ............ 376
• Types ........ ........... 377
• Sinus Bradycardia ........ ............ 378
• Sinus Tachycardia ........ ............ 379
• Sinus Nodal Re-entrant Tachycardia ........ ........ 379
32. Abnormal Atrial Rhythm (Atrial Arrhythmias or Dysarrhythmias) ........ 382
• Atrial Arrhythmias ........ .......... 382
• Atrial Ectopics (Extrasystoles or Premature Beats) ........ 382
• Atrial Bigeminy/Trigeminy ........ ........ 385
• Atrial Interpolated Beat ........ ........ 385
• Atrial Escape Beat ........ ............ 385
• Ectopic Low Atrial Rhythm ........ ........ 385
• Atrial Parasystole ........ ........ 386
• Wandering Atrial Pacemaker Rhythm........ ...... 386
• Atrial Tachycardias ........ ......... 387
• Review at Glance ........ ........ 390
• Atrial Re-entrant Tachycardia ........ ......... 390
• Multifocal Atrial Tachycardia (MAT) ........ ....... 390
• Chaotic Atrial Rhythm ........ ......... 391
• Atrial Flutter ........ ........ 391
• Review at a Glance ........ .......... 394
• Atrial Fibrillation (AF) ........ .......... 394
• Review at Glance ........ ........ 397
33. Atrioventricular (AV) Nodal Disturbances ........... 398
• AV Nodal (Junctional) Escape Beats (Read Chapter 40—Escape Rhythm) ......... 400
• Premature AV Nodal (Junctional) Complexes/AV Nodal Extrasystoles or Ectopics .......... 402
• AV Nodal (Junctional) Rhythm ........ ............ 403
• Acceleration of AV Nodal Rhythm (Accelerated AV Nodal Rhythm or Idionodal Tachycardia) ............ 403
34. Paroxysmal Supraventricular Tachycardias ........ 408
Definition ........ ......... 408
Mechanisms ........ ........... 408
Atrioventricular (AV) Nodal Tachycardias ........ ... 409
35. Ventricular Arrhythmias/Dysarrhythmias ............ 416
• Ventricular Ectopics or Extrasystoles ........ ........ 416
• Idioventricular Rhythms ........ ........... 425
Contents
xxi
• Ventricular Tachycardia (VT) ........ .......... 428
• Torsades De Pointes ........ ........ 435
• Ventricular Flutter ........ ........... 436
• Ventricular Fibrillation (VF) ........ ........ 436
• Ventricular Asystole ........ ........ 437
• Dying Heart (Agonal Rhythm) Pattern ........ ..... 438
• Other Diagnostic Electrocardiographic Techniques for Arrhythmias ........ 438
36. Reciprocal Rhythm and Reciprocal Tachycardia ........ 443
• Reciprocal Rhythm ........ .......... 443
• WPW Syndrome and Reciprocating Rhythm/Tachycardia ........ 448
• Tachycardia through Atrio-hisian Pathway (Lown-Ganong-Levine Syndrome with Tachycardia) ........ 452
• Tachycardias through Mahaim Fibers ........ ...... 452
37. Atrioventricular Dissociation .......... 455
• Etiology ........ ........ 456
• Mechanisms ........ ......... 456
38. Parasystole ........ 462
• Parasystolic Ventricular Tachycardia ........ ........ 464
• Atrial Parasystole and Parasystolic Atrial Tachycardia ......... 464
• Nodal Parasystole ........ ............ 465
39. Ventricular Aberrancy or Aberrant Intraventricular Conduction .......... 467
• Phasic Aberrant Intraventricular Conduction ........ 467
• Ventricular Aberrancy........ .......... 473
• Atrial Fibrillation with Ventricular Aberration ........... 477
• Atrial Flutter with Ventricular Aberration ........ 480
• Ventricular Aberrancy versus Intermittent Bundle Branch Block......... 482
40. Escape Rhythm ........ 484
Escape Beats and Escape Rhythm ........ ........ 484
41. Ventricular Fusion Beats .......... 490
Ventricular Fusion Complexes or Beats ........ ......... 490
42. Ventricular Capture Beats ........ 493
• Types of Ventricular Capture ........ .......... 493
• Timing and Conduction of Capture Beats ........ 494
• Electrocardiographic Characteristics of a Capture Beat ......... 494
• Significance ........ .......... 495
SECTION ELEVEN
Artificial Pacemakers
43. Artificial Pacemakers .......... 499
• Electrocardiographic Patterns of Paced Complexes ............ 509
• Malfunctioning of Pacemakers ........ ........ 511
• Pacemaker Re-entrant Tachycardia (Endless Loop Tachycardia) ......... 516
• Pacemaker Syndrome ........ ........... 517
Textbook of Clinical Electrocardiography
xxii
SECTION TWELVE
Miscellaneous Disorders
44. Heart in Endocrine Disorders and Injuries .......... 521
• Hyperthyroidism (Thyrotoxicosis) ........ ............ 521
• Hypothyroidism (Myxoedema) ........ ............ 521
• Acromegaly ........ .......... 523
• Cushing’s Syndrome ........ ............ 523
• Adrenal Insufficiency ........ ........... 523
• Pheochromocytoma (Catecholamines Excess) ........ 524
• Parathyroid Disorders ........ .......... 524
• Physical Injuries ........ ........ 524
• Hypothermia ........ ........ 524
• Electrical Injuries ........ ........ 525
• Drowning ........ .......... 525
• Trauma to the Heart ........ ........ 525
• Tumors of the Heart ........ ........ 525
45. Drugs, Poisons and the Heart ......... 528
• Drugs and the Heart ........ ........ 528
• Phenothiazines and Other Antipsychotic Drugs ......... 534
• Antidepressants ........ ........ 534
• Heart in Systemic Poisonings ........ .......... 536
• Heart in Envenomation ........ ........ 540
46. The Electrolytes and the Heart ............ 544
• Electrolyte Disturbances ........ ............ 544
• Hypokalemia ........ ........ 544
• Hyperkalemia ........ ........... 547
• Hypercalcemia ........ .......... 550
• Hypocalcemia ........ ........... 551
• Hypomagnesemia ........ ............ 552
• Hypermagnesemia ........ .......... 552
• Uremia ........ ......... 552
47. Heart in Cerebrovascular and Neuromuscular Disorders......... 554
• Cerebrovascular Accident (CVA) ........ ......... 554
• Hypokalemic and Hyperkalemic Periodic Paralysis ........... 554
• Neuromuscular Disorders ........ ......... 556
Appendices
Appendix A
• Normal 12-Lead Surface ECG and its Variations in Adults ........ 563
Appendix B ........ 565
• Analysis of an Arrhythmia ........ ......... 565
Appendix C ........ 567
• Proforma for ECG Reporting ........ ........... 567
Index ......... 569
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