ECGs for Beginners Antoni Bayés de Luna Emeritus Professor of Cardiology, Autonomous University of Barcelona Senior Investigator, Institut Català Ciències Cardiovasculars Hospital Sant Pau Senior Consultant, Hospital Quiron Barcelona, Spain Copyright © 2014 by John Wiley & Sons, Inc All rights reserved Published by John Wiley & Sons, Inc., Hoboken, New Jersey Published simultaneously in Canada No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 750-4470, or on the web at www.copyright.com Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008, or online at http://www.wiley.com/go/permissions The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions Readers should consult with a specialist where appropriate The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read No warranty may be created or extended by any promotional statements for this work Neither the publisher nor the author shall be liable for any damages arising herefrom For general information on our other products and services or for technical support, please contact our Customer Care Department within the United States at (800) 762-2974, outside the United States at (317) 572-3993 or fax (317) 572-4002 Wiley also publishes its books in a variety of electronic formats Some content that appears in print may not be available in electronic formats For more information about Wiley products, visit our web site at www wiley.com Library of Congress Cataloging-in-Publication Data: Bayés de Luna, Antoni, 1936– author ECGs for beginners / Antoni Bayés de Luna p ; cm Includes bibliographical references and index ISBN 978-1-118-82131-2 (pbk.) I Title [DNLM: 1. Electrocardiography–methods. 2. Heart Diseases–diagnosis. WG 330] RC683.5.E5 616.1'207547–dc23 2014012635 Cover image courtesy of the author Contents Preface, vii Forewords to Previous Editions, ix Foreword, x Part I: The Normal Electrocardiogram, Anatomical and Electrophysiological Bases, The ECG Curve: What Is It and How Does It Originate?, 11 Recording Devices and Techniques, 33 ECG Interpretation, 40 Part II: Morphological Abnormalities in the ECG, 59 Atrial Abnormalities, 61 Ventricular Enlargements, 68 Ventricular Blocks, 84 Ventricular Preexcitation, 102 Myocardial Ischemia and Necrosis, 111 Part III: The ECG in Arrhythmias, 161 10 Concepts, Classification, and Mechanisms of Arrhythmias, 163 11 ECG Patterns of Supraventricular Arrhythmias, 179 12 ECG Patterns of Ventricular Arrhythmias, 193 13 The ECG Patterns of Passive Arrhythmias, 208 14 How to Interpret ECG Tracings with Arrhythmia, 217 Part IV: ECG in Clinical Practice, 221 15 From Symptoms to the ECG: ECGs in the presence of precordial pain or other symptoms, 223 16 The ECG in Genetically Induced Heart Diseases and Other ECG Patterns with Poor Prognosis, 231 17 ECG Recordings in Other Heart Diseases and Different Situations, 246 18 Abnormal ECG Without Apparent Heart Disease and Normal ECG in Serious Heart Disease, 258 Bibliography, 262 Index, 267 v Preface It is my pleasure to present this ECG book for beginners, a book that I would have liked to own when I began to study electrocardiography It has been written with beginners in mind, therefore it is a book for ‘readers with little knowledge of the subject’ who want to learn ‘quickly and didactically’, uncovering what appears to be complex or mysterious because in fact it is an essential part of their professional work Figures and diagrams, many of them already published in my previous books, in combination with a succinct text have been carefully put together for this purpose I am proud to be able to help these readers so that the study of the ECG may be easier for them It is something I have always tried to in my nearly 50 years as a university professor, and something my students have often remarked on I have written previous and more extensive ECG books in English, Catalan and Spanish in the last 40 years, which have been translated into eight languages with more than 20 editions However, this new book is special because it contains the essentials of the ECG: the cheapest, the quickest and most useful technique that has existed in medicine for over 100 years This book contains text in bold that indicates certain points that I feel are especially important The reader will also find letters in the margins that refer to key concepts for a correct understanding of the ECG At the end of each chapter, these reference points are used in a short quiz for selfassessment In this way, residents of any medical specialization, not only cardiology, but also general practitioners, intensivists, anesthesiologists, pediatricians, medical students, and nurses will be able to understand normal and pathologic ECG morphologies, recognizing the patterns and understanding how they originate My objective has been to decode the electrocardiographic curve into an understandable sequence representing the electrical activation of the heart so that it may be followed step-by-step, from the initial stimulus in the sinus node to the ventricular myocardium I explain how the P wave, the QRS complex, and the T wave morphologies originate, and how they occur in both normal and pathologic conditions It is not advisable to memorize the ECG patterns, but rather understand deductively how they occur With this in mind, I have included more figures and less text The book is comprised of four parts and 18 chapters The first part outlines the basic normal ECG; the second the typical morphologies in different pathologies; the third the ECG patterns of arrhythmias and the fourth part deals with the important to use correctly the ECG in the clinical context of the patient This is really the most important aim of modern clinical electrocardiography If a certain concept is not fully understood, the reader should not despair A second reading is often all that is needed I am also happy to help through internet correspondence Complementary resources are available as well, including our recent volumes ‘Clinical Arrhythmology’ and ‘Clinical Electrocardiography’ (Wiley-Blackwell, 2011 and 2012, respectively) These books are more extensive and include exhaustive reference sections, while this book lists only the essential references Finally, I would like to add one important last piece of advice The clinical context is extremely relevant in the interpretation of ECGs, and is often the deciding factor when interpreting a case As a rule we should not assume that if a normal ECG is present we can rule out heart disease, just as we should not become too alarmed with certain vii viii Preface isolated pathological ECG patterns because they may represent something nonspecific I would like to thank each and every reader for their interest in this book I would also like to express my respect and admiration for those authors whose books helped in my training: Drs Grant and Marriot in the U.S., Dr Stock in the U.K., Drs Sodi and Cabrera in Mexico, Dr Tranchesi in Brazil, and Drs Rosenbaum and Elizari in Argentina and others whom I have consulted, and who are listed in the Bibliography I am very grateful to my close collaborators: Drs J Riba, M Fiol, A Bayés-Genís, and also to J Guindo, D Goldwasser, A Baranchuk, J García Niebla and D Conde, as well as my previous fellows W Zareba, R Brugada, I Cygankiewicz, P Iturralde, R Baranowski and X Viñolas and many others, because all of them have been my greatest source of inspiration and support I also thank Montserrat Saurí and Joan Crespo and in the last period Esther Gregoris, my secretariat team, who are so hard-working and always cheerful I would also lie to thank the Menarini Co, namely and especially Dr M Ballarin, for their logistical support I lovingly thank my wife Maria Clara, who has always tolerated my hectic pace, as well as my five children and 13 grandchildren, who know that I will always be there for them . . . albeit with pen in hand Antoni Bayés de Luna Cathedral Square Vic Christmas 2014 abayes@csic-iccc.org Forewords to Previous Editions Textbook of Clinical Electrocardiography, Martinus Nijhoff Publishers, 1993 Dr Antonio Bayés de Luna is not only an expert in the use of the electrocardiogram as a diagnostic tool, but as clearly demonstrated in this text, he is a highly skilled teacher of its appropriate use This text provides this knowledge in a clear manner at all levels of sophistication Hein J.J Wellens, Maastricht, 1993 Basic Electrocardiography, Futura Blackwell, 2007 Prof Antoni Bayes de Luna, the author of this textbook, is a world-wide renowned electrocardiographer and clinical cardiologist who has contributed to our knowledge and understanding of electrocardiography over the years This textbook is an asset for every cardiologist, internist, primary care physician as well as medical students interested in broadening their skills in electrocardiography Yochai Birnbaum, Texas, 2007 Clinical Arrhythmology, Wiley Blackwell, 2011 I felt that this book demonstrated the great authority of the author as well as his deep knowledge of clinical arrhythymology and electrocardiography, great didactic capabilities and many years of experience in this field I am sure that it will be extremely useful for readers Valentí Fuster, New York, 2011 Clinical Arrhythmology, Wiley Blackwell, 2011 His various books on electrocardiography, published in the most common languages are known by every admirer of the electrical activity of the heart No cardiologist has described the ECG in as much detail as he His detailed work has consisted of the nearly impossible job of dissecting the electrical activity of the heart Pere Brugada, Brussels, 2011 Clinical Electrocardiography: A Textbook, Wiley Blackwell, 2012 Professor Antoni Bayes de Luna is a master cardiologist who is the most eminent electrocardiographer in the world today As a clinician he views the electrocardiogram as the means to an end, the evaluation of a patient with known or suspected heart disease, rather than as an end in itself In an era of multi-authored texts which are often disjointed and present information that is repetitive and even contradictory, it is refreshing to have a body of information which speaks with a single authoritative respected voice Clinical Electrocardiography is such a book Eugene Braunwald, Boston, 2011 ix Foreword This new edition, the 12th, of Prof Antoni Bayés de Luna’s classic book on clinical electrocardiography, is especially important ‘for beginners’ and reinforces the clinical utility of the surface electrocardiogram It is quite evident that ECG patterns cannot be memorized without a clear clinical understanding of the subject This is different from other textbooks on electrocardiography Notably, Prof A Bayés de Luna has presented up-to-date, well explained concepts as well as new evidence to explain the pathophysiology of ECG patterns Prof Bayés has worked tirelessly to research the electrophysiological mechanisms that explain electrical changes and has systematically organized these ideas The reader will find an explanation and the clinical relevance of the significant diagnostic and therapeutic repercussions in any abnormality seen in the ECG As his pupils and collaborators for many years, we greatly value his teachings, which have reached many countries throughout the world; since the publication of the first edition in 1977, the book has been translated into more than 10 languages While this book has already become classic ECG reading material around the world, this new edition stands out because of its particularly large quantity of figures, more than in previous editions, and because of the importance placed on the correlation between ECG findings and those obtained by cardio MRI At the same time, the book contains new tables that summarize important aspects and mistakes typically made when first learning ECG interpretation or when the latest electrocardiographic information has not been made available x This book represents 40 years of meticulous, innovative, and even obsessive study by its author As his fellows, we are extremely proud to present this work and recommend it to all who wish to understand the complexity of ECG recordings After so many years on the front line, Prof A Bayés de Luna continues to surprise us with new ideas and possible new explanations for difficult ECG tracings He is a very gifted specialist in this field His tenacity and discipline in writing this work on his own has allowed the text to be agile and flow easily from one section to another Like Braunwald or Hurst, Bayés de Luna is classic reading The four parts allow the reader to become familiar with the normal ECG and the various pathologic patterns, including ventricular enlargement, ventricular block, and arrhythmias Antoni Bayés de Luna is Professor Emèritus in Cardiology at the Universitat Autònoma de Barcelona Since 2006 his research group has published 59 articles and nine books, all during a period in his life when many of his fellow professionals are considering retirement He has lectured internationally on 20 occasions and has recently overseen the 51st annual clinical electrocardiography course Congratulations Professor, and please, never slow down! Miquel Fiol Sala Cap de l’Unitat Coronària i Director de l’Institut de Biomedicina Hospital Son Espases, Palma Antoni Bayés Genis Cap Servei de Cardiologia H Germans Trias i Pujol Badalona Professor Titular de Cardiologia, UAB ... promotional statements for this work Neither the publisher nor the author shall be liable for any damages arising herefrom For general information on our other products and services or for technical support,... this ECG book for beginners, a book that I would have liked to own when I began to study electrocardiography It has been written with beginners in mind, therefore it is a book for ‘readers with... publishes its books in a variety of electronic formats Some content that appears in print may not be available in electronic formats For more information about Wiley products, visit our web site