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above-mentioned copyright This work was completed outside of Dr Strauss’ duties at the U.S Food and Drug Administration (FDA) This book reflects the views of the authors and should not be construed to represent FDA’s views or policies Printed in China Library of Congress Cataloging-in-Publication Data Wagner, Galen S., author Marriott’s practical electrocardiography — Twelfth edition / Galen S Wagner, David G Strauss p ; cm Practical electrocardiography Includes bibliographical references and index ISBN 978-1-4511-4625-7 (alk paper) I Strauss, David G., author II Title III Title: Practical electrocardiography [DNLM: Electrocardiography Heart Diseases—diagnosis WG 140] RC683.5.E5 616.1’207547—dc23 2013036495 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication Application of the information in a particular situation remains the professional responsibility of the practitioner The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly important when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320 International customers should call (301) 223-2300 Visit Lippincott Williams & Wilkins on the Internet: at LWW.com Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to pm, EST 10 Dedicated to Marilyn Wagner, Mya Sjogren, and Molly and Michael Strauss Contents Digital Contents Contributors Foreword Preface SECTION I: BASIC CONCEPTS CHAPTER CARDIAC ELECTRICAL ACTIVITY Galen S Wagner, Tobin H Lim, and David G Strauss The Book: Marriott's Practical Electroardiography, 12th Edition The Electrocardiogram Anatomic Orientation of the Heart The Cardiac Cycle Cardiac Impulse Formation and Conduction Recording Long-Axis (Base-Apex) Cardiac Electrical Activity Recording Short-Axis (Left versus Right) Cardiac Electrical Activity CHAPTER RECORDING THE ELECTROCARDIOGRAM Galen S Wagner, Raymond R Bond, Dewar D Finlay, Tobin H Lim,and David G Strauss The Standard 12-Lead Electrocardiogram Correct and Incorrect Electrode Placements Alternative Displays of the 12 Standard Electrocardiogram Leads Alternative Electrode Placement Other Practical Points for Recording the Electrocardiogram CHAPTER INTERPRETATION OF THE NORMAL ELECTROCARDIOGRAM Galen S Wagner, Tobin H Lim, David G Strauss, and Jacob Simlund Electrocardiographic Features Rate and Regularity P-Wave Morphology The PR Interval Morphology of the QRS Complex Morphology of the ST Segment T-Wave Morphology U-Wave Morphology QTc Interval Cardiac Rhythm CHAPTER THE THREE-DIMENSIONAL ELECTROCARDIOGRAM Charles W Olson, E Harvey Estes, Jr., Vivian Paola Kamphuis, Esben A Carlsen, David G Strauss, and Galen S Wagner Perspective Three-Dimensional Electrocardiography Depolarization—The QRS Vector Loop The Vectorcardiogram Recording a Vectorcardiogram The Vectorcardiogram and the Electrocardiogram Visualizing Vector Loops from the Electrocardiogram SECTION II: ABNORMAL WAVE MORPHOLOGY CHAPTER CHAMBER ENLARGEMENT David G Strauss, Ljuba Bacharova, Galen S Wagner, and Tobin H Lim Chamber Enlargement Atrial Enlargement Systematic Approach to the Evaluation of Atrial Enlargement Ventricular Enlargement Right-Ventricular Dilation Right-Ventricular Hypertrophy Left-Ventricular Dilation Left-Ventricular Hypertrophy Ventricular Enlargement CHAPTER INTRAVENTRICULAR CONDUCTION ABNORMALITIES David G Strauss, Tobin H Lim, and Galen S Wagner Normal Conduction Bundle-Branch and Fascicular Blocks Unifascicular Blocks Bifascicular Blocks Systematic Approach to the Analysis of Bundle-Branch and Fascicular Blocks Clinical Perspective on Intraventricular-Conduction Disturbances CHAPTER VENTRICULAR PREEXCITATION Galen S Wagner Historical Perspective Clinical Perspective Pathophysiology Electrocardiographic Diagnosis of Ventricular Preexcitation Electrocardiographic Localization of the Pathway of Ventricular Preexcitation Ablation of Accessory Pathways CHAPTER INHERITED ARRHYTHMIA DISORDERS Albert Y Sun and Galen S Wagner The Long QT syndrome Electrocardiographic Characteristics Electrocardiogram as Used in Diagnosis The Short QT syndrome Electrocardiographic Characteristics Electrocardiogram as Used in Diagnosis The Brugada Syndrome Arrhythmogenic Right-Ventricular Cardiomyopathy/Dysplasia J Wave Syndrome CHAPTER MYOCARDIAL ISCHEMIA AND INFARCTION David G Strauss, Peter M van Dam, Tobin H Lim, and Galen S Wagner Introduction to Ischemia and Infarction Electrocardiographic Changes CHAPTER 10 SUBENDOCARDIAL ISCHEMIA FROM INCREASED MYOCARDIAL DEMAND David G Strauss, Tobin H Lim, and Galen S Wagner Changes in the ST Segment CHAPTER 11 TRANSMURAL MYOCARDIAL ISCHEMIA FROM INSUFFICIENT BLOOD SUPPLY David G Strauss, Tobin H Lim, and Galen S Wagner Changes in the ST Segment Changes in the T Wave Changes in the QRS Complex Estimating Extent, Acuteness, and Severity of Ischemia CHAPTER 12 MYOCARDIAL INFARCTION David G Strauss, Tobin H Lim, and Galen S Wagner Infarcting Phase Chronic Phase Myocardial Infarction and Scar in the Presence of Conduction Abnormalities CHAPTER 13 MISCELLANEOUS CONDITIONS Galen S Wagner and David G Strauss Cardiomyopathies Pericardial Abnormalities Pulmonary Abnormalities Intracranial Hemorrhage Endocrine and Metabolic Abnormalities Electrolyte Abnormalities Drug Effects SECTION III: ABNORMAL RHYTHMS CHAPTER 14 INTRODUCTION TO ARRHYTHMIAS Galen S Wagner and David G Strauss Approach to Arrhythmia Diagnosis Problems of Automaticity Problems of Impulse Conduction: Block Problems of Impulse Conduction: Reentry Clinical Methods for Detecting Arrhythmias Dynamic (Holter) Monitoring Transtelephonic Monitoring Memory Loop Monitoring Invasive Methods of Recording the Electrocardiogram Incidences of Arrhythmias in Healthy Populations Ladder Diagrams CHAPTER 15 PREMATURE BEATS Galen S Wagner Premature Beat Terminology Differential Diagnosis of Wide Premature Beats Mechanisms of Production of Premature Beats Atrial Premature Beats Junctional Premature Beats Ventricular Premature Beats The Rule of Bigeminy Right- versus Left-Ventricular Premature Beats Multiform Ventricular Premature Beats Groups of Ventricular Premature Beats Ventricular Premature Beats Inducing Ventricular Fibrillation Prognostic Implications of Ventricular Premature Beats CHAPTER 16 ACCELERATED AUTOMATICITY Galen S Wagner Introduction to Accelerated Automaticity Sinus Tachycardia Atrial Tachyarrhythmias Accelerated Junctional Rhythm Accelerated Ventricular Rhythm CHAPTER 17 REENTRANT ATRIAL TACHYARRHYTHMIAS—THE ATRIAL FLUTTER/FIBRILLATION SPECTRUM Galen S Wagner and David G Strauss Paroxysmal Atrial Tachycardia Atrial Rate and Regularity in Atrial Flutter/Fibrillation Ventricular Rate and Regularity in Atrial Flutter/Fibrillation Onset of Atrial Flutter/Fibrillation Termination of Atrial Flutter/Fibrillation Atrial Flutter Patterns of Atrioventricular Conduction Atrial Fibrillation Characteristics of the f Waves of Atrial Fibrillation Patterns of Atrioventricular Conduction Atrial Flutter/Fibrillation with Ventricular Preexcitation CHAPTER 18 REENTRANT JUNCTIONAL TACHYARRHYTHMIAS Marcel Gilbert, Galen S Wagner, and David G Strauss Introduction to Reentrant Junctional Tachyarrhythmias Varieties of Reentrant Junctional Tachyarrhythmias Conduction through the Atria and Ventricles Differentiation from Other Tachyarrhythmias Differentiation between AV Nodal and AV-Bypass Tachycardias The Two Varieties of AV Nodal Tachycardia The Three Varieties of AV-Bypass Tachycardia CHAPTER 19 REENTRANT VENTRICULAR TACHYARRHYTHMIAS Marcel Gilbert, Galen S Wagner, and David G Strauss Varieties of Ventricular Tachyarrhythmias Description Etiologies Diagnosis Variation of Duration in Ventricular Tachycardia Variations in the Electrocardiographic Appearance of Ventricular Tachycardia: Torsades de Pointes Ventricular Flutter/Fibrillation CHAPTER 20 VENTRICULAR VERSUS SUPRAVENTRICULAR WITH ABERRANT CONDUCTION Galen S Wagner Circumstances Producing Aberrancy Characteristics Ventricular Aberration Complicating Atrial Flutter/Fibrillation Critical Rate Paradoxical Critical Rate CHAPTER 21 DECREASED AUTOMATICITY Galen S Wagner Mechanisms of Bradyarrhythmias of Decreased Automaticity Sinoatrial Block Perspective on Sinus Pauses CHAPTER 22 ATRIOVENTRICULAR BLOCK Galen S Wagner Severity of Atrioventricular Block Location of Atrioventricular Block Atrioventricular Nodal Block Infranodal (Purkinje) Block CHAPTER 23 ARTIFICIAL CARDIAC PACEMAKERS ... LIM, AND DAVID G STRAUSS THE BOOK: MARRIOTT’S PRACTICAL ELECTROCARDIOGRAPHY, 12TH EDITION What Can This Book Do for Me? This 12th edition of Marriott’s Practical Electrocardiography has been specifically... Cataloging-in-Publication Data Wagner, Galen S., author Marriott’s practical electrocardiography — Twelfth edition / Galen S Wagner, David G Strauss p ; cm Practical electrocardiography Includes bibliographical... electrocardiographic teaching and research challenges for the past years One of the strengths of Marriott’s Practical Electrocardiography through its more than 50-year history has been its lucid foundation