Clinical Electrocardiography: A Simplified Approach, 7th Edition (2006)

Preface

This book is an introduction to electrocardiography. It is written particularly for medical students, house staff, and nurses, and it assumes no previous instruction in ECG reading. The book has been widely used in introductory courses on the subject. Clinicians wishing to review basic electrocardiography have also found it useful.

This new edition is divided into four parts. Part 1 covers the basic principles of electrocardiography, normal ECG patterns, and the major abnormal depolarization (P-QRS) and repolarization (ST-T-U) patterns. Part 2 describes the major abnormalities of heart rhythm and conduction. Part 3 presents an overview and review of the material. Part 4 is primarily a set of unknowns for review and self-assessment. In addition, practice questions are presented at the end of almost all chapters. In reading ECGs, as in learning a new language, fluency is attained only with repetition and review.

The clinical applications of ECG reading have been stressed throughout the book. Each time an abnormal pattern is mentioned, the conditions that might have produced it are discussed. Although the book is not intended to be a manual of therapeutics, general principles of treatment and clinical management are briefly discussed. Separate chapters are devoted to important special topics, including electrolyte and drug effects, cardiac arrest, the limitations and uses of the ECG, and electrical devices, including pacemakers and implantable cardioverter defibrillators (ICDs).

In addition, students are encouraged to approach ECGs in terms of a rational simple differential diagnosis rather than through the tedium of rote memorization. It is comforting for most students to discover that the number of possible arrhythmias that can produce a heart rate of more than 200 beats per minute is limited to just a handful of choices. Only three basic ECG patterns are found with cardiac arrest. Similarly, only a limited number of conditions cause low-voltage patterns, abnormally wide QRS complexes, and so forth.

In approaching any given ECG, “three and a half” essential questions must always be addressed: What does the ECG show and what else could it be? What are the possible causes of this pattern? What, if anything, should be done about it? Most conventional ECG books focus on the first question (“What is it?”), emphasizing pattern recognition. However, waveform analysis is only a first step, for example, in the clinical diagnosis of atrial fibrillation. The following questions must also be considered: What is the differential diagnosis? (“What else could it be?”). Are you sure the ECG actually shows atrial fibrillation, and not another “look-alike pattern,” such as multifocal atrial tachycardia, sinus rhythm with atrial pre- mature beats, or even an artifact due to parkinsonian tremor? What could have caused the arrhythmia? Treatment (“What to do?”), of course, depends in part on the answers to these questions.

The continuing aim of this book, therefore, is to present the ECG as it is used in hospital wards, outpatient clinics, emergency departments, and intensive care units, where recognition of normal and abnormal patterns is only the starting point in patient care.

The seventh edition contains updated discussions on multiple topics, including arrhythmias and conduction disturbances, cardiac arrest and sudden death, myocardial ischemia and infarction, drug toxicity, pacemakers, and implantable cardioverter-defibrillators (ICDs). Common pitfalls in ECG interpretation are highlighted. Review questions throughout the text have been revised and updated.

This new edition also includes laminated cards on differential diagnosis for “instant” reference and review.

This edition is dedicated to the memory of my father, Emanuel Goldberger, MD, a pioneer in the development of electrocardiography and the inventor of the aVR, aVL, and aVF leads. He was coauthor of the first five editions of this textbook.

Finally, I want to thank my students and colleagues for their input and particularly for their challenging questions over the years. I am most grateful to my son, Zach Goldberger, MD, for his many helpful suggestions and comments in the preparation of this new edition.