Abstract
This chapter presents ten cases with characteristic electrocardiographic (ECG) findings that should not be missed. The first case demonstrates the chronological ECG changes seen during ST segment elevation myocardial infarction. The case presenting sinus node dysfunction (SND) highlights the various ECG manifestations of SND. The case of atrioventricular (AV) block highlights the approach to the diagnosis of 2:1 AV block. The case of Wolff–Parkinson–White (WPW) syndrome describes the diagnostic ECG criteria for WPW syndrome and the supraventricular tachycardias associated with it. The wide complex tachycardia (WCT) case presents a stepwise algorithmic approach to the diagnosis of WCT. The case of hypertrophic cardiomyopathy focuses on risk stratification for sudden death. We present the characteristic ECG findings in patients with Brugada syndrome, long QT syndrome, and early repolarization syndrome that are causes of sudden death in young patients without structural heart disease. Finally, we present the approach to the diagnosis of artifact on the ECG that is important to prevent expensive workups and unnecessary treatments.
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Wagner GS, Macfarlane P, Wellens H, et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part VI: acute ischemia/infarction: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol. 2009;53(11):1003–11.
Mendis S, Thygesen K, Kuulasmaa K, et al. World Health Organization definition of myocardial infarction: 2008–09 revision. Int J Epidemiol. 2011;40(1):139–46.
Huang HD, Birnbaum Y. ST elevation: differentiation between ST elevation myocardial infarction and nonischemic ST elevation. J Electrocardiol. 2011;44(5):494.e491–12.
Badhwar N, Kusumoto F, Goldschlager N. Arrhythmias in the coronary care unit. J Intensive Care Med. 2012;27(5):267–89.
Adan V, Crown LA. Diagnosis and treatment of sick sinus syndrome. Am Fam Physician. 2003;67(8):1725–32.
Brignole M. Sick sinus syndrome. Clin Geriatr Med. 2002;18(2):211–27.
Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;51(21):e1–62.
Barold SS. 2:1 Atrioventricular block: order from chaos. Am J Emerg Med. 2001;19(3):214–7.
Maury P, Zimmermann M, Metzger J. Distinction between atrioventricular reciprocating tachycardia and atrioventricular node re-entrant tachycardia in the adult population based on P wave location; should we reconsider the value of some ECG criteria according to gender and age? Europace. 2003;5(1):57–64.
Arruda MS, McClelland JH, Wang X, et al. Development and validation of an ECG algorithm for identifying accessory pathway ablation site in Wolff-Parkinson-White syndrome. J Cardiovasc Electrophysiol. 1998;9(1):2–12.
Fitzpatrick AP, Gonzales RP, Lesh MD, Modin GW, Lee RJ, Scheinman MM. New algorithm for the localization of accessory atrioventricular connections using a baseline electrocardiogram. J Am Coll Cardiol. 1994;23(1):107–16.
Keating L, Morris FP, Brady WJ. Electrocardiographic features of Wolff-Parkinson-White syndrome. Emerg Med J. 2003;20(5):491–3.
Vereckei A, Duray G, Szenasi G, Altemose GT, Miller JM. Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia. Eur Heart J. 2007;28(5):589–600.
Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83(5):1649–59.
Kindwall KE, Brown J, Josephson ME. Electrocardiographic criteria for ventricular tachycardia in wide complex left bundle branch block morphology tachycardias. Am J Cardiol. 1988;61(15):1279–83.
Pava LF, Perafan P, Badiel M, et al. R-wave peak time at DII: a new criterion for differentiating between wide complex QRS tachycardias. Heart Rhythm. 2010;7(7):922–6.
Pelliccia A, Zipes DP, Maron BJ. Bethesda Conference #36 and the European Society of Cardiology Consensus Recommendations revisited a comparison of U.S. and European criteria for eligibility and disqualification of competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol. 2008;52(24):1990–6.
Rao U, Agarwal A. Importance of Q waves in early diagnosis of hypertrophic cardiomyopathy. Heart. 2011;97(23):1993–4.
Antzelevitch C, Brugada P, Borggrefe M, et al. Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation. 2005;111(5):659–70.
Antzelevitch C, Brugada P, Brugada J, Brugada R. Brugada syndrome: from cell to bedside. Curr Probl Cardiol. 2005;30(1):9–54.
Priori SG, Napolitano C, Gasparini M, et al. Natural history of Brugada syndrome: insights for risk stratification and management. Circulation. 2002;105(11):1342–7.
Brugada J, Brugada R, Antzelevitch C, Towbin J, Nademanee K, Brugada P. Long-term follow-up of individuals with the electrocardiographic pattern of right bundle-branch block and ST-segment elevation in precordial leads V1 to V3. Circulation. 2002;105(1):73–8.
Viskin S. Torsades de Pointes. Curr Treat Options Cardiovasc Med. 1999;1(2):187–95.
Lepeschkin E, Surawicz B. The measurement of the Q-T interval of the electrocardiogram. Circulation. 1952;6(3):378–88.
Jackman WM, Friday KJ, Anderson JL, Aliot EM, Clark M, Lazzara R. The long QT syndromes: a critical review, new clinical observations and a unifying hypothesis. Prog Cardiovasc Dis. 1988;31(2):115–72.
Schwartz PJ, Priori SG, Spazzolini C, et al. Genotype-phenotype correlation in the long-QT syndrome: gene-specific triggers for life-threatening arrhythmias. Circulation. 2001;103(1):89–95.
Priori SG, Schwartz PJ, Napolitano C, et al. Risk stratification in the long-QT syndrome. N Engl J Med. 2003;348(19):1866–74.
Schwartz PJ, Crotti L. QTc behavior during exercise and genetic testing for the long-QT syndrome. Circulation. 2011;124(20):2181–4.
Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004;44(3):E1–211.
Haissaguerre M, Derval N, Sacher F, et al. Sudden cardiac arrest associated with early repolarization. N Engl J Med. 2008;358(19):2016–23.
Tikkanen JT, Junttila MJ, Anttonen O, et al. Early repolarization: electrocardiographic phenotypes associated with favorable long-term outcome. Circulation. 2011;123(23):2666–73.
Viskin S, Rosso R, Halkin A. Making sense of early repolarization. Heart Rhythm. 2012;9(4):566–8.
Antzelevitch C, Yan GX. J wave syndromes. Heart Rhythm. 2010;7(4):549–58.
Aizawa Y, Sato A, Watanabe H, et al. Dynamicity of the J-wave in idiopathic ventricular fibrillation with a special reference to pause-dependent augmentation of the J-wave. J Am Coll Cardiol. 2012;59(22):1948–53.
Littmann L, Monroe MH. Electrocardiographic artifact. N Engl J Med. 2000;342(8):590–1; author reply 592.
Krasnow AZ, Bloomfield DK. Artifacts in portable electrocardiographic monitoring. Am Heart J. 1976;91(3):349–57.
Patel SI, Souter MJ. Equipment-related electrocardiographic artifacts: causes, characteristics, consequences, and correction. Anesthesiology. 2008;108(1):138–48.
Adams-Hamoda MG, Caldwell MA, Stotts NA, Drew BJ. Factors to consider when analyzing 12-lead electrocardiograms for evidence of acute myocardial ischemia. Am J Crit Care. 2003;12(1):9–16; quiz 17–8.
Mirvis DM, Berson AS, Goldberger AL, et al. Instrumentation and practice standards for electrocardiographic monitoring in special care units. A report for health professionals by a Task Force of the Council on Clinical Cardiology, American Heart Association. Circulation. 1989;79(2):464–71.
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El Hage, L., Badhwar, N., Goldschlager, N. (2014). Top Ten Electrocardiographic (ECG) Abnormalities Not to Miss. In: Stergiopoulos, K., Brown, D. (eds) Evidence-Based Cardiology Consult. Springer, London. https://doi.org/10.1007/978-1-4471-4441-0_11
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DOI: https://doi.org/10.1007/978-1-4471-4441-0_11
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