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About the Book

 

The electrocardiogram can serve as an independent identifier of myocardial disease or reflect anatomic, metabolic, hemodynamic, or electrophysiological alterations in the heart. It can provide information that is often essential for the proper diagnosis and therapy of a variety of disorders and is without equal as a method for diagnosing cardiac arrhythmias. It is the procedure of choice for patients who present with chest pain, dizziness, syncope, or symptoms that may indicate risk of myocardial infarction or sudden death.

Family physicians are often the first, and sometimes the only, point of contact for many patients within the health care system. The standard 12-lead electrocardiogram is one of the most common tests obtained and interpreted by the family physician, with most of the physicians reading their own recordings and basing clinical decisions on their findings. It has been shown that family physicians can achieve proficiency in the interpretation of over 95 percent of all electrocardiogram findings seen in the primary care setting.

Although computerized interpretation is widely available, it is considered unreliable in up to 20 percent of the cases, making competency and interpretation by family physicians an essential skill. This book provides the necessary skills for family physicians to use in interpreting electrocardiograms, both in their offices and in the emergency rooms of their hospitals. It also should prove of value to other primary care physicians, as well as medical students and residents of nearly all medical specialties.

As the subtitle states, this book is about the essential elements involved in electrocardiographic interpretation. It is not all inclusive; however, it does cover the abnormalities most likely to be seen by family physicians in their everyday practice of medicine.

This book is an outgrowth of a course I taught in the Department of Family Medicine at the University of Mississippi School of Medicine and five articles titled Electrocardiography for the Family Physician I subsequently published in Family Practice Recertification.

In short, this book is the one I wish I had access to during the many years I actively practiced family medicine and when I was a resident in family medicine.

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Contents
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Chapter 1. General Principles of Electrophysiology     1

Electrocardiograph Interpretation     2

Electrocardiograph Paper     2

Conduction System of the Heart     3

Parts of the Electrocardiogram     4

Deflections     4

Intervals     8

Segments     11

ST-T Complex     12

J Point     13

 

Chapter 2. Leads and normal electrocardiogram    14

Leads   14

The Limb Leads     15

The Chest Leads     17

Lead Combinations     19

The Normal EKG     19

Mean Electrical Activity     19

Criteria     20

 

Chapter 3. Heart Rate and Axis     23

Heart Rate     23

Axis     24

Right Axis Deviation     24

Left Axis Deviation     26

Northwest Axis     26

Determining the Axis of the Mean Vector     26

 

Chapter 4. Atrial Enlargement and Ventricular Hypertrophy

Atrial Enlargement     31

Right Atrial Enlargement     31

Left Atrial Enlargement     32

Biatrial Enlargement     33   

Ventricular Hypertrophy     33

Right Ventricular Hypertrophy     33

Left Ventricular Hypertrophy     34

Ventricular Overload (Strain)     36

Biventricular Hypertrophy     37

 

Chapter 5. Intraventricular Conduction Disturbances     38

Right Bundle Branch Block     38

Left Bundle Branch Block     40

Incomplete Bundle Branch Block     41

Hemiblocks     42

Bifascicular Block     42

Nonspecific Intraventricular Conduction Defects

      43

 

Chapter 6. Myocardial Ischemia, Myocardial Infarction, and Pseudoinfarction Syndromes     44

Myocardial Ischemia     44

Classic Angina     44

Other Causes of ST Segment Depression     46

Prinzmetal’s Angina     46

Other Causes of ST Segment Elevation     47

Myocardial Infarction   47

Transmural Myocardial Infarction     47

Subendocardial Infarction     52

Pseudoinfarction Syndromes     52

Chapter 7. Rhythm Disturbances     54

Normal Sinus Rhythm     54

Sinus Arrhythmias     55

Sinus Tachycardia     55

Sinus Bradycardia     55

Sinoatrial Block     56

Sick Sinus Syndrome     56

Non-sinus Atrial Arrhythmias     57

Premature Atrial Contraction     57

Paroxysmal Atrial Tachycardia     58

Multifocal Atrial Tachycardia     58

Atrial Flutter     59

Atrial Fibrillation     60  

Junctional Rhythms     61

Premature Junctional Contraction

      61

Junctional Tachycardia     61

Junctional Escape Rhythm     62

Ventricular Rhythm Disturbances     62

Premature Ventricular Contractions  62

Ventricular Tachycardia     63

Ventricular Fibrillation     65

Idioventricular Rhythm   65

Supraventricular Beat with Aberrancy     66

Atrioventricular Heart Block     67

First-degree Heart Block     67

Second-degree Heart Block     67

Third-degree Heart Block     68

Bigeminy     69

 

Chapter 8. Preexcitation Syndromes, Early Repolarization, Pulmonary Embolus, and Pericarditis     70

Preexcitation Syndromes     70

Wolff-Parkinson-White Syndrome     70

Lown-Ganong-Levine syndrome     72

Early Repolarization     74  

Pulmonary Embolus     74  

Pericarditis     75

Stages of Pericarditis     75

Acute Pericarditis versus Myocardial Infarction versus

     Early Repolarization    76

 

Chapter 9. Athletic Heart Syndrome, Ventricular Pacemaker, Drug Effects, Electrolyte Effects, EKG Worksheet, and Practice EKG     78

Athletic Heart Syndrome     78

Ventricular Pacemaker     79

Drug Effects     79

Digitalis     79

Quinidine     80

Electrolyte Effects     80

Potassium     81

Calcium     81

EKG Worksheet     82

Practice EKG     83

 

Appendix: A Quick Review of Electrocardiography     86

 

Index     111


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