John R. Hampton-The ECG Made Easy-Churchill Livingstone ().pdf The aims 'The Basics' explains the ECG in the simplest of this edition are the same. The. ECG. Made Easy. EIGHTH EDITION. John R. Hampton. DM MA DPhil FRCP FFPM FESC. Emeritus Professor of Cardiology. University of Nottingham, UK. 𝗣𝗗𝗙 | A true medical classic should be novel, stimulate thought and discussion, Hampton encourages the reader to consider this most complex of patterns as.

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ECG. PROBLEMS. John R. Hampton. Emeritus Professor of Cardiology. University of Made Easy or The ECG in Practice is fine so far as it goes, but it. J-R-Hampton-ECG-made-easy fisdupartmerworl.ml - Download as PDF File .pdf) or read online. The ECG Made Easy John R. Hampton. This famous book encourages the reader to accept that the ECG is easy to understand and that its صيغة الكتاب: pdf.

During the process of the recording the signal is calculated and amplified from the 10 electrodes placed on your body and subsequently recorded on a piece of graph paper with specific dimensions. There are 12 such leads in a regular 12 lead ECG, each of which analyse a different plane of the heart and are therefore useful in diagnosing different conditions and localising disease. The leads on the chest are called unipolar leads because their vector is only pointing in one direction i.

There are 4 electrodes on the patients limbs, but only 3 of which are used to form leads and one which is used as an earth, just like the one found on a plug for an electrical device. The 3 limb electrodes used are the right arm, the left arm and the left leg. The leads are formed by using various combinations of the 3 leads, with leads I-III using 2 electrodes to form a vector bipolar leads and leads aVR, aVL and aVF using 3 electrodes augmented bipolar leads.

Each box represents a specific time interval since the ECG always records at a particular velocity. By counting these boxes horizontally, the doctor is able to discern the heart rate as well as the timings of the different parts of the ECG. The heart rate, the timings of the intervals as seen in the diagram below , the height of the recording as well as the leads in which the abnormalities are present all help to make a diagnosis.

The image also highlights the electrical activity in the heart at the time, that causes the distinctive wave. Depolarisation indicates that a wave of electricity has just passed through an area of the heart such as the ventricles of atria, causing them to contract. What can you expect after an ECG? After the ECG recording is made, the leads will be removed from your body and the doctor present will attempt to make a diagnosis on the basis of what was found.

If the ECG shows a serious abnormality, or there is more information that is needed, other investigations which are more interventional may be indicated, for example an echocardiogram an ultrasound examination of the heart. What are some possible results from an ECG and what do these mean?

There are a very large number of possible disorders that can be found on an ECG, but there are some main categories into which a majority of the abnormalities can be grouped. Abnormalities of the left heart Abnormalities of the right heart Abnormalities of the atria Abnormally slow rates bradycardias and conduction blocks Heart attacks What these abnormalities mean depends on their severity and the patient in question.

Ambulatory ECG Ambulatory ECG monitoring refers to the recording of the hearts electrical activity while a person is active and going about their daily life. This is commonly performed in patients where there is a need to determine associations between what is seen on the ECG and the symptoms that the patient is experiencing. Indications for ambulatory ECG An ambulatory ECG is useful for monitoring patients who are at a high risk of heart problems that may not show up in the short space of time that they have in a clinic.

It is especially useful for the following peoples: Unclear diagnosis: When a clear diagnosis cannot be obtained in the short space of time available in a clinical setting, an ambulatory ECG allows the doctor to gain information about the heart over a whole day, allowing for a much clearer assessment. Fainting: Syncope fainting and presyncope lightheadedness can both be caused by small alterations in heart rhythm that only occur very infrequently.

An ambulatory monitor allows these to be picked up due to the length of time it will be monitoring the heart. Pacemaker assessment: In people in whom there is a suspected malfunction in a pacemaker, an ambulatory ECG gives detailed information about how the pacemaker is coping with various aspects of day to day life.

Following a heart attack: After a heart attack, assessing the rhythm throughout the day under various conditions and stresses allows the doctor to have a more accurate picture of how strong the heart is following the infarction. Follow-up of abnormal rhythm: Looking at the heart over a longer period of time can help to see if there are any periods of abnormal rhythm that may be missed if an ECG was only conducted in the doctors surgery.

Types of recorders There are many different types of recorders available, some of which include: Continuous full disclosure recording systems: The device can record for 12 or more hours and the whole recording can then be inspected and linked to any signs and symptoms Event recorders memory loop devices : These can be used as an alternative to continuous recorders, especially for patients who experience their symptoms less than once a day.

In a junctional extrasystole there is Fig. However, when they QRS complex Fig. The QRS complexes occur early in the T wave of a preceding beat of atrial and junctional extrasystoles are, of they can induce ventricular fibrillation see p.

Ventricular extrasystoles, however, have It may, however, not be as easy as this, abnormal QRS complexes, which are typically particularly if a beat of supraventricular origin wide and can be of almost any shape Fig.

QRS complex and an abnormal T wave: It is advisable 4.

Is the T wave the same way up as in the to get into the habit of asking five questions normal beat? In supraventricular beats, it every time an ECG is being analysed: Does an early QRS complex follow an early 5. Does the next P wave after the extrasystole P wave? If so, it must be an atrial extrasystole. In both 2. Can a P wave be seen anywhere?

P wave cycle Fig. If the causing a sustained tachycardia. The difference between this important thing is to try to identify a P wave. In first, second or 3. In the record in Figure 3. The QRS complex is of normal seen in any lead. Note Sinus rhythm: It is the latter which is important in the and is always worth trying because it may make diagnosis and treatment of arrhythmias. Carotid the nature of the arrhythmia more obvious sinus pressure completely abolishes some Fig.

Carotid sinus pressure activates a supraventricular arrhythmias, and slows the reflex that leads to vagal stimulation of the SA ventricular rate in others, but it has no effect and AV nodes.

This causes a reduction in the on ventricular arrhythmias. Excitation has to spread by an abnormal path through the ventricular muscle, and the QRS complex is therefore wide and abnormal. Finding P waves and seeing how they relate help to differentiate between the two possible to the QRS complexes is always the key causes of a tachycardia with broad QRS to identifying arrhythmias. Always look complexes.

If a patient with an acute myocardial carefully at a full lead ECG. If possible, compare the QRS complex will almost always be ventricular tachycardia. Fibrillation can occur in have the same shape as during normal the atrial or ventricular muscle. When the atrial muscle fibres contract 4. Left axis deviation during the tachycardia independently there are no P waves on the usually indicates a ventricular origin, as ECG, only an irregular line Fig.

At times does any change of axis compared with a there may be flutter-like waves for 2—3 s. The record taken during sinus rhythm. AV node is continuously bombarded with 5. If during the tachycardia the QRS complex depolarization waves of varying strength, and is very irregular, the rhythm is probably depolarization spreads at irregular intervals atrial fibrillation with bundle branch block down the His bundle.

The AV node conducts see below. Because conduction into and All the arrhythmias discussed so far have through the ventricles is by the normal route, involved the synchronous contraction of all the each QRS complex is of normal shape.

When individual often be seen much better in some leads than in muscle fibres contract independently, they are others Fig. Lead V1: The accessory identified, and the ECG is totally disorganized bundles form a direct connection between the Fig. The PR interval is short, due to a loose connection, the diagnosis is easy. Some more detail in Chapter 7. Depolarization can certainly accounts for some tachycardias, others IP spread down the His bundle and back up the are due to re-entry circuits within the heart For more accessory pathway, and so reactivate the atrium.

Although this — Sinus tachycardia: For fast or slow sinus rhythm, treat the the arrhythmia or may have no effect. Extrasystoles rarely need treatment. In patients with acute heart failure or low in block e. Patients with any bradycardia that is has no effect. IP affecting the circulation can be treated 6. Narrow complex tachycardias should For more on with atropine, but if this is ineffective they be treated initially with adenosine.

Wide complex tachycardias should pp. WPW syndrome. Is the abnormality occasional or sustained? Are there any P waves? Are there as many QRS complexes as P waves? Are the ventricles contracting regularly extent like recognizing an elephant — once seen, IP or irregularly?

However, in cases of difficulty 5. Is the QRS complex of normal shape? For more on it is helpful to ask the following questions, tachycardias, 6. What is the ventricular rate? Is the QRS complex of normal duration? Is the ST segment raised or depressed? Abnormalities of the T wave 98 6. Is the T wave normal?

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Other abnormalities of the ST segment Remember: The P wave can only be normal, unusually tall or unusually broad. Then ask the following questions — always too tall, and it may contain an abnormal in the same sequence: Q wave. Are there any abnormalities of the P wave? The ST segment can only be normal, 2. What is the direction of the cardiac axis? Apart from alterations of the shape of the P wave 2. Left atrial hypertrophy usually due to mitral associated with rhythm changes, there are only stenosis causes a broad and bifid P wave two important abnormalities: Anything that causes the right atrium to become hypertrophied such as tricuspid Fig.

Since characteristics: Its duration is no greater than ms three in lead V1 becomes upright i. In a right ventricular lead V1 , the S wave this is nearly always abnormal Fig. There is greater than the R wave.

In a left ventricular lead V5 or V6 , the height of the R wave is less than 25 mm. Left ventricular leads may show Q waves due to septal depolarization, but these are less than 1 mm across and less than 2 mm deep. In each case, the increased width S indicates that depolarization has spread V6 through the ventricles by an abnormal and therefore slow pathway.

Peaked P waves. Right axis deviation S waves in lead I. In pulmonary embolism the ECG may show 3. Tall R waves in lead V1. Right bundle branch block. Inverted T waves in lead V1 normal , abnormal other than sinus tachycardia. When a spreading across to lead V2 or V3.

A shift of transition point to the left, of the following: If in doubt, V4 clockwise rotation. A deep S wave will treat the patient with an anticoagulant. Left ventricular hypertrophy causes a tall R However, do not hesitate to treat the patient if wave greater than 25 mm in lead V5 or V6 the clinical picture suggests pulmonary embolism and a deep S wave in lead V1 or V2 Fig.

It is difficult to diagnose minor degrees of left ventricular hypertrophy from the ECG. However, Q waves greater than one small square in width representing 40 ms and greater than 2 mm in depth have a quite different significance.

The ventricles are depolarized from inside 4. Therefore, an electrode If the infarction involves both the anterior placed in the cavity of a ventricle would record and lateral surfaces of the heart, a Q wave will only a Q wave, because all the depolarization be present in leads V3 and V4 and in the leads waves would be moving away from it.

Q waves greater than one small square in The right ventricle occupies the front of the width and at least 2 mm deep therefore indicate heart anatomically, and normally depolarization a myocardial infarction, and the leads in which of the right ventricle moving towards the the Q wave appears give some indication of the recording electrode V1 is overshadowed by part of the heart that has been damaged.

Thus, depolarization of the left ventricle moving away infarction of the anterior wall of the left from V1. The result is a dominant S wave in lead ventricle causes a Q wave in the leads looking V1. For more on myocardial becomes more obvious, and a dominant R wave The presence of a Q wave does not give any infarction, see develops in lead V1.

The appearance of the ECG indication of the age of an infarction, because once pp. The leads between the T wave and the next P wave — but in which the elevation occurs indicate the part Fig. Downward-sloping — as opposed to horizontally Horizontal depression of the ST segment, depressed — ST segments are usually due to associated with an upright T wave, is usually a treatment with digoxin see p.

The older term for the in lead V3 in some black people. Ischaemia Left ventricular hypertrophy causes inverted T 3.

Genetic influence on electrocardiogram time intervals and heart rate in aging mice

Ventricular hypertrophy waves in leads looking at the left ventricle I, II, 4. Right ventricular 5. Digoxin treatment. Subsequently, Q waves appear, and branch block is usually associated with an the T waves become inverted. The ST segment abnormal path of repolarization. Therefore, returns to the baseline, the whole process taking inverted T waves associated with QRS a variable time but usually within the range complexes which have a duration of ms or 24—48 h.

T wave inversion is often permanent. A high depression of the ST segment Fig. It is potassium level causes peaked T waves with helpful to record an ECG before giving digoxin, the disappearance of the ST segment.

The QRS to save later confusion about the significance of complex may be widened. The effects of T wave changes. T wave and QT interval measured from the onset of the QRS complex to the end of the T wave are most commonly affected. T wave inversion is associated with ECG and in complexes originating in the bundle branch block, ischaemia, and IP ventricular muscle. It is also seen in ventricular hypertrophy.

For more on the Wolff—Parkinson—White syndrome. Right be due to electrolyte abnormalities, but see pp. For example, Figure 5. All the ECGs in this chapter came from health screening clinics, and we The T wave will assume that the individuals considered U waves themselves to be healthy. Automated ECG reporting often fails to do this. Supraventricular extrasystoles are of no clinical Occasional ventricular extrasystoles are significance, although atrial extrasystoles need experienced by many people with normal hearts.

In an individual patient, however, their medically when they are so frequent as to presence is not a good predictor of such risk.

This does not cause symptoms and When depolarization is initiated from a focus is usually of no clinical significance. Tall P waves alone may indicate tricuspid The upper limit of the PR interval in a normal stenosis, but this is rare. However, the ECGs of healthy individuals, ECG Bifid P waves in the absence of signs of especially athletes, not uncommonly have PR IP associated left ventricular hypertrophy can intervals slightly longer than ms, and these For an example indicate mitral stenosis now fairly rare , but a can be ignored in the absence of any other mitral stenosis, bifid and not particularly prolonged P wave is indication of heart disease.

The ECG in Figure 5. Nevertheless, PR interval The P waves of atrial extrasystoles tend to be prolongation to this extent is probably evidence ECG abnormally shaped compared to the P waves of of disease of the conducting tissue.

IP the sinus beats of the same patient Fig. Second degree heart block of the Mobitz 1 For more on P waves cannot always be seen in all leads, Wenckebach type may be seen in athletes, but hyperkalaemia, but if there is a total absence of P waves the otherwise second and third degree block are see p.

It is common in healthy subjects, the patient has had a myocardial infarction, particularly if they are tall, as with the ECG in raising the possibility of left posterior Figure 5. Right bundle branch block with Depolarization of the whole ventricular muscle a QRS complex duration greater than ms mass should occur within ms, so this is sometimes seen in healthy subjects, but represents the maximum width of the normal should be taken as a warning of things like an QRS complex.

Any widening indicates atrial septal defect. Partial incomplete right conduction delay or failure within the bundle bundle branch block RSR1 pattern in lead V1, branch system, pre-excitation see below , or a but with a QRS complex duration less than ventricular origin of depolarization — any of ms; Fig.

The QRS complex 5 Fig. The deviation, or T wave inversion in leads V2—V3 , Sokolow—Lyon criteria define left ventricular this can be a normal variant Fig. In fact these criteria are unreliable, and a QRS If the QRS complexes seem too small to be complex height greater than 25 mm is often consistent with the clinical findings, check the ECG seen in fit young men.

Left ventricular calibration of the ECG recorder. If this is correct, IP hypertrophy can only be diagnosed with possible explanations of small QRS complexes For more on left confidence when tall QRS complexes are are obesity, emphysema and pericardial effusion. This is sometimes referred to developed changes of an ST segment elevation see pp. Narrow Q likely to be normal, even when associated with waves in the inferior and lateral leads Fig. These features and sometimes even quite deep ones, may also often disappear if the ECG is repeated with the be perfectly normal.

Occasionally, a normal heart may be Tall and peaked T waves Fig. Peaked T hypokalaemia. However, the best examples of waves are also associated with hyperkalaemia, prominent U waves come from normal people ECG but in fact some of the tallest and most peaked Fig.

V6 septal Q waves. There are a few features of chest pain that The ECG in patients with intermittent make the diagnosis obvious. Chest pain that chest pain radiates to the teeth or jaw is probably cardiac The ECG in patients with breathlessness in origin; pain that is worse on inspiration is either pleuritic or due to pericarditis; and pain in the back may be due to either myocardial Chest pain is a very common complaint, and ischaemia or aortic dissection.

The ECG will when reviewing the ECG of a patient with help to differentiate these causes of pain but it chest pain it is essential to remember that there is not infallible — for example, if an aortic Box 6.

The ECG In Practice

The first is infarction the rupture of atheromatous plaque within a associated with ST segment elevation, known as coronary artery. The diagnosis of lost. If a patient has chest pain and there is ECG Box 6. The diagnosis of anti-platelet agents and a beta-blocker. STEMI can also be accepted if there is left During the first few hours after the onset of bundle branch block which is known to be new. Otherwise, after a repeatedly in a patient with chest pain that variable time, usually within a day or so, the ST could be due to cardiac ischaemia, but whose segments return to the baseline, the T waves in ECG is nondiagnostic.

If In unstable angina there is ST segment anterior ST segment elevation persists, a left depression while the patient has pain Fig. Once the pain has resolved the ECG returns to Figures 6.

These that is damaged: This is with inferior infarction. A few days later pain and a few days later, and they show the Fig. Figure 6.

In a routine ECG there will be dominant R wave that can be a normal variant. Normal ECG. Raised ST segments. Appearance of Q waves. Normalization of ST segments. Inversion of T waves. However, there is Fig. With time the T waves may revert now treatment PCI or thrombolysis that can to normal, but inversion may persist.

Patients whose chest pain is due to oesophageal 1 2. If a diagnosis of angina is in doubt, ECG changes can be induced by exercise.

The has great advantages over coronary angiography: The onset of any symptoms. After confidently be made if there is horizontal ST For more on recording the ECG at rest, exercise is segment depression of at least 2 mm. If the ST exercise testing, progressively increased in stages of 3 min. The segments are depressed but upward-sloping, see pp. Figures 6. The two low-level stages the 6. The ECG in patients with intermittent chest pain 6 Fig. ECG evidence of cardiac When the ECG of a breathless patient shows enlargement may point to the cause of an arrhythmia or a conduction abnormality, or breathlessness.

For example, ECG evidence evidence of ischaemia or of atrial or ventricular of left ventricular hypertrophy may be due to hypertrophy, then the breathlessness may be hypertension or to mitral or aortic valve disease.

V1 or V2 greater than 35 mm. Pulmonary embolism often presents as a In practice, it is not a very reliable indicator combination of chest pain and breathlessness.

Although the chest pain is characteristically one-sided and pleuritic, a major embolus affecting the main pulmonary arteries may cause pain resembling that of myocardial infarction. This is because the heart is rotated, diseases do not usually cause the ECG changes with the right ventricle occupying more of the associated with severe pulmonary hypertension, precordium than usual.

The only way of NORMAL ECGs being certain that a cardiac problem is the cause of either phenomenon is to record an Symptoms may not be due to heart disease — the ECG when the patient is having a typical patient may have epilepsy or some other attack, but this is seldom possible.

Nevertheless, condition. In a young associated with exercise think of anaemia or person, who is unlikely to have coronary disease, anxiety, and the palpitations build up and slow this pattern pattern suggests hypertrophic down, sinus tachycardia is likely to be the cause cardiomyopathy Fig.

In paroxysmal tachycardia, with arrhythmias, syncope and sudden death. In both cases an abnormal block, which may be due to aortic stenosis; or pathway bypasses the atrioventricular AV node, right ventricular hypertrophy, which may be causing the short PR interval.

This may be pathway connects the atrium and the ventricle, confused with right ventricular hypertrophy. In the WPW syndrome type A, the right-sided, connecting the right atrium and pathway is left-sided, connecting the left right ventricle, and this is called the WPW atrium and left ventricle, and causes a syndrome type B Fig. Here, lead V1 has dominant R wave in lead V1 Fig. Figure 7.

A few seconds before the cardiac arrest, he A QTc interval longer than ms is likely developed a transient broad complex tachycardia to be abnormal. QT interval prolongation can in which the QRS complexes were initially be congenital, but is most often due to drugs, upright but then changed, to become particularly to antiarrhythmic drugs Box 7.

Box 7. It can also be associated with a variety of Fig. However, such It is important to consider the possible combinations may also be associated with higher underlying causes of heart block, and these are degrees of block, and ambulatory recording may summarized in Box 7.

The QRS complexes in paroxysmal change of axis compared to sinus rhythm; tachycardia can be narrow i. Narrow complex tachycardias may indicate: Figure bundle branch block is normally present. It is usually temporary, predominantly upwards or downwards and does not need pacing unless there is in the chest leads.

When complete block complicates an to be atrial fibrillation with bundle branch anterior STEMI, a large amount of myocardium block, or atrial fibrillation in the WPW has usually been damaged, and temporary syndrome a dangerous combination. When no spontaneous activity is sensed, the pacemaker Pacemakers produce a small electrical discharge stimulates the right ventricle; and when that either replaces the function of the sinoatrial spontaneous activity is sensed, the pacemaker is node or bypasses a blocked His bundle.

The inhibited. The ECG looks like that in Figure 7. If the pacemaker does not sense Pacemaker function can be assessed from the spontaneous atrial depolarization, it stimulates resting ECG. If no atrial activity is sensed within a predetermined 1. The first letter describes the chamber s period, the atrial pacing lead will pace. A paced A for right atrium, V for right maximum PR interval is also predetermined, ventricle or D for dual, i.

The second letter describes the chambers will be paced. A pacemaker inhibition. The fourth letter R is used when the rate one or two pacing leads. In either pulseless electrical activity PEA.

The The shockable rhythms are ventricular treatment sequence after the first two steps is: Action in either case, following 1.

Adrenaline 1 mg i. CPR Atropine 3 mg i. Precordial thump. If unsuccessful, continue adrenaline 1 mg 2. One shock at J. Resume chest compressions at Particularly in cases of PEA, consider 4. If unsuccessful, defibrillate at J. If unsuccessful, give adrenaline 1 mg i.With time the T waves may revert now treatment PCI or thrombolysis that can to normal, but inversion may persist. The ECG in healthy subjects 6.

This eighth edition differs from its predecessors in that it has been divided into two parts. Sometimes it is used to mean the pieces of wire that connect the patient to the ECG recorder.

If unsuccessful, continue adrenaline 1 mg 2. It is It takes longer than in a normal heart for seldom of significance, and can be considered excitation to reach the right ventricle because to be a normal variant. LBBB is common in and hypokalaemia may be the main cause of electrolyte aortic stenosis.