Normal ECG and Chamber Enlargement

• Brief Review of Cardiac Anatomy and Physiology
• Electrical Activity of the Heart
• Functions of an Electrocardiograph
• How the ECG Machine Measures Current Direction
• The ECG of Ventricular Depolarization
• The ECG of Ventricular Repolarization
• The Dipole Concept
• Electrocardiographic Language of Direction

• The Bipolar Limb Leads 1, 2 and 3
• The Triaxial System and Einthoven's Triangle
• The Triaxial System - Determining QRS Duration
• The Triaxial System - QRS Direction Recognition
• The Triaxial System - Direction by the Method of Perpendiculars
• The Unipolar Limb Leads
• How to Draw a Frontal Plane Hexaxial System
• Plotting Vectors in the Hexaxial System
• The Semicircle Method of Plotting Frontal Vectors

• Placing the Chest Electrodes
• Plotting Vectors with the Horizontal Plane Hexaxial System
• How to Draw a Spatial Vector

• The Normal Frontal Plane QRS Range
• The Normal Frontal Plane T Range
• The Normal Frontal Plane P Range
• Frontal Plane Indeterminate Axes
• Effects of Age and Chest Shape on Frontal Plane QRS Axes
• Normal Horizontal Plane QRS Ranges and Patterns
• Horizontal Plane Normal T Ranges and Patterns
• Horizontal Plane Normal P Ranges and Patterns
• Pediatric P, QRS and T Directions
• How to Recognize a Normal ECG

• Basic Terminology
• ECG Paper Speed and Time Markings
• Applying the ECG Electrodes
• Special ECG Leads
• Patient and Bed Aspects
• Lead Reversal and Lead Placement Artifacts
• Artifacts

• The Problem of Increased Voltage
• Frontal Plane LVH Criteria
• Horizontal Plane LVH Criteria
• Secondary LVH Criteria
• Secondary Horizontal Plane LVH Criteria
• The LVH Strain Pattern
• Other Secondary T Criteria for LVH
• Causes of Reduced Voltage
• Acquired Ventricular Dilatation
• Complete Bundle Branch Block and LVH
• The Significance of LVH on the ECG in Systolic Overloads
• Volume Overloading of the Left Ventricle

• Frontal Plane Criteria for RVH
• The Frontal Plane ECG in Emphysema or COPD
• The Horizontal Plane ECG in Emphysema or COPD
• Pectus Excavatum Versus Emphysema
• Cachectic Heart Versus COPD
• Horizontal Plane RVH Criteria - Anterior QRS in RVH
• Horizontal Plane RVH Criteria - Posterior QRS in RVH
• Horizontal Plane RVH Criteria - R/S Ratio Regression Sign
• Initial V1 Negativity in RVH
• S-T, T in the Right Precordium with RVH
• Right Ventricular Systolic or Pressure Overloading
• RVH of Pulmonary Stenosis
• RBBB Pattern and Right Ventricular Overloading
• RVH with Acute Pulmonary Embolism
• Right Ventricular Diastolic Overload Pattern
• Combined Ventricular Overloads and Differential Diagnosis of RVH

• General Principles of Atrial Overload
• The P Axis in Right Atrial Overload
• The P Axis in COPD
• P Pulmonale and Pseudo P Pulmonale in RA Overload
• Horizontal Plane Signs of Right Atrial Overload
• The Ta Wave and P-R Segment
• Left Atrial Overload - Physiology and Etiologies
• Wide, Notched P Waves (Intraatrial Block) in LA Overload
• The P Axis in Left Atrial Overloads
• Horizontal Plane Signs of Left Atrial Overload
• Left Atrial Overload in Coronary Disease
• Atrial Overloads in Atrial Arrhythmias

• Systematic Approach to Reading an Electrocardiogram

Myocardial Infarction and T Wave Changes

• General Vector Rules in Myocardial Infarction
• Direction of Initial Forces in Myocardial Infarction
• Pathogenesis and Recognition of Necrosis Vectors
• Recognition of a Necrosis Vector in the Frontal Plane
• Recognizing Sites of Infarction by Frontal Plane Necrosis Changes
• Horizontal Plane Necrosis Changes
• Posterior Infarction
• Normal Septal Versus Infarct Vectors in the Horizontal Plane
• Uncovering Hidden Necrosis Vectors
• Infarction in the Presence of LBBB
• LBBB Initial Vectors Versus Infarct Vectors
• Right Ventricular Overload Initial Vectors Mimicking Necrosis
• Normal Q Wave in Lead 3 Versus Inferior Infarction

• Hemiblocks or Divisional Blocks
• Anterior Divisional Blocks - Definitions of Left Axis Deviation
• Anterior Divisional Blocks - Significance of Left Axis Deviation
• Anterior Divisional Blocks and Left Precordial S Waves
• Left Axis Deviation With No Divisional Blocks
• LVH and Anterior Divisional Blocks
• Congenital Heart Disease With Possible ADBs
• Posterior Divisional Blocks
• Initial Vector in Divisional Blocks
• Bifascicular and Trifascicular Blocks
• Masquerading Bundle Branch Block
• Postdivisional LBBB and QRS Axis
• Trifascicular and Quadrifascicular Blocks or Delays
• Diagnosis of Divisional Blocks
• Etiologies and Prognoses of Bifascicular and Trifascicular Blocks
• Lev's Disease and Lenegre's Disease
• Periinfarction Blocks
• Imitators of Classic Periinfarction Block, or Divisional Blocks With Terminal Slowing Plus a Necrosis Vector

• Normal Repolarization Process
• Genesis and Direction of the Injury Current
• Frontal Plane Sites of Infarction
• Horizontal Plane Sites
• Significance of the Injury Current
• Pericarditis Versus Infarction
• Early Repolarization Versus Pericarditis
• Left Ventricular Hypertrophy Strain Pattern Versus an Injury Current
• Digitalis S-T Vector Versus the LVH Strain Pattern
• Subendocardial Current of Injury
• J Wave and Hypothermia
• Exercise Testing
• Criteria for an Ischemic S-T Response to Exercise Testing
• How to Avoid False Positive Exercise Tests
• How to Avoid False-Negative Exercise Tests for Ischemia
• Vasospastic Angina Pectoris S-T Abnormalities

• Direction of the Normal T Vector
• QRS-T Angle
• Shape and Duration of the Ischemic T
• T Direction in Myocardial Infarction
• Age of Infarct
• T Negativity in Pericarditis
• Postextrasystolic T Abnormalities

• Tall T Wave Differential Diagnosis
• Q-T Interval
• Q-T and Hypercalcemia
• Q-T and T in Hypocalcemia
• U Wave
• Negative U Waves
• Relatively High U Wave
• Hypocalcemia and U Waves
• T Waves of Cardiomyopathies (Myocardial Infiltration, Fibrosis, Inflammation)
• Notched T Waves
• Digitalis Effect on the T Wave
• T Wave In Hypothyroidism

• Types of T Abnormalities and Syndromes Associated with  a Normal Myocardium
• Juvenile T Pattern
• Neurotic Heart T Syndrome
• Hyperventilation Syndrome T Abnormalities
• S-T, T Abnormalities and the Valsalva Maneuver
• Isolated T Negativity Syndrome
• Benign T Negativity of Athletes
• Cerebral Autonomic T Abnormalities
• Prolapsed Mitral Valve Syndrome
• Suspended Heart Syndrome
• T Inversion of Schizophrenia
• Summary of Maneuvers to Identify Physiologic T Abnormalities
• T Waves After Artificial Pacing

• Systematic Approach to Reading an Electrocardiogram

Blocks, Pre-excitation Syndromes, and Arrhythmias

Initial Activation and the Septal Vector

• Initial Activation and the Septal Vector

• Initial QRS Vector in Right Bundle Branch Block
• Direction of the Terminal QRS Vector in Right Bundle Branch Block
• Terminal Slowing in Right Bundle Branch Block
• Complete and Incomplete Right Bundle Branch Block
• Right Bundle Branch Block Pattern
• Axis in Right Bundle Branch Block
• Initial Vector in Left Bundle Branch Block
• Mid-QRS Forces in Left Bundle Branch Block
• Terminal QRS Forces and Intrinsicoid Deflections in Left Bundle Branch Block
• Complete and Incomplete Left Bundle Branch Block
• Summary of Criteria for Left Bundle Branch Block
• Secondary S-T, T Changes of Bundle Branch Block
• Significance of Right and Left Bundle Branch Block

Initial Vector Abnormalities in Preexcitation Syndromes

• Classic Wolff-Parkinson-White Syndrome
• Classifying Wolff-Parkinson-White Types
• Eliciting the Accessory AV Bundle Type of Preexcitation
• Delta Wave Masking and Mimicking Effects
• Nonatrioventricular Accessory Bundle Preexcitation (Mahaim Fibers)
• Nonatrioventricular Accessory Bundle Preexcitation (James Fibers and Short P-R, Normal QRS Preexcitation)

Bundle of His Recordings

• Technique
• Intervals From the His Bundle Electrogram
• Summary of What Has Been Learned or Confirmed About the Conduction System by His Bundle Electrograms

• Reading Heart Rates
• Sinus Tachycardia and Bradycardia
• Automatic Control of the SA Node
• Sinus Arrhythmia
• Natural Pacemakers and the Transmembrane Action Potential
• Phase 4 and Heart Rate
• Phase 4 and Dominant Pacemakers
• SA Block and Sinus Arrest
• Sinus Node Dysfunction and the Sick Sinus Syndrome
• AV Nodal Conduction Properties
• First-Degree AV Block
• Laddergram
• Second-Degree AV Block (Type 1)
• Second-Degree AV Block (Type 2)
• Complete AV Block
• Complete AV Block (Pacemaker Site and Chacteristics)
• Complete AV Block (Atria in Complete AV Block)
• Complete AV Block (Complete AV Block with Acute Myocardial Infarction)
• Supernormal Conduction
• Escape Beats
• Escape Pacemakers with Myocardial Infarction
• Atrial Ectopic Beats and Pacemakers (Physiology of Automatic Cells)
• P Wave Directions and Atrial Ectopic Sites
• Premature Atrial Contractions
• P' in Junctional and Low Atrial Pacemakers
• P'-R and P'-P Intervals
• Hidden Ectopic P Wave Diagnosis
• Aberrant Conduction with Premature Atrial Contractions
• Right and Left Atrial Dissociation

Arrhythmias: PVCs, Alternans, and Ectopic Tachycardias

• Premature Ventricular Contractions
• Site and Origin of PVCs
• Timing of PVCs in the Cycle
• Post-PVC Perfect Compensatory Pause
• Interpolated PVCs
• Group Beating
• Concealed Extrasystoles
• Possible Causes of PVCs (Reentry Theory)
• Multiform Versus Multifocal PVCs
• Ectopic Focus Theory
• PVCs Versus Parasystole (Parasystole Defined)
• Parasystole and Coupling
• Parasystolic Entrance and Exit Blocks
• Parasystole and Fusion Beats
• Parasystole Recognition
• Reciprocal Beats
• Ectopic Tachycardias
• Atrial Fibrillation - Atrial and Ventricular Rates
• Atrial Fibrillation - Characteristics of f Waves
• Atrial Fibrillation and Digitalis
• Causes of Atrial Fibrillation
• Atrial Fibrillation with Aberrant Conduction
• Atrial Flutter F Wave Characteristics
• Atrial Flutter: F Wave-QRS Relations
• Causes of Atrial Flutter
• Atrial Tachycardia
• Atrial Tachycardia - Reciprocal Beat Theory
• Atrial Tachycardia in WPW and LGL Syndromes
• Atrial Tachycardia with Block
• Atrial Tachycardia - Junctional Tachycardias
• Atrial Tachycardia - Wandering and Shifting Atrial Pacemakers
• Atrial Tachycardia - Multifical or Chaotic
• Isorhythmic Dissociation
• Electrical Alternans
• Ventricular Tachycardia
• Mechanisms and Causes of Ventricular Tachycardia
• Chronic VT
• Differentiation of VT from Supraventricular Tachycardias
• AV Dissociation
• Capture and Fusion Beats
• Distinguishing VT from Its Most Common Mimic
• Bidirectional Tachycardia
• Ventricular Flutter and Fibrillation
• Systematic Approach to Interpretation of an Arrhythmia

Electronic Pacemakers

• Electronic Pacemakers
• Fixed-Rate Pacemakers
• Demand Pacemakers
• Three-Letter Pacemaker Code
• Pacemaker Failure
• Recognition of Implantion Site
• Pacemaker Arrhythmias

• Systematic Approach to Reading an Electrocardiogram