150 ECG Cases

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Table of Contents

Cover image

Title Page

Copyright

How to use this book

Part 1 Everyday ECGs

Part 2 More Challenging ECGs

Further Reading

Preface

Introduction: making the most of the ECG

Part 1 Everyday ECGs

ECG 1

ECG 2
ECG 3

ECG 4

ECG 5

ECG 6

ECG 7

ECG 8

ECG 9

ECG 10

ECG 11

ECG 12

ECG 13

ECG 14

ECG 15

ECG 16
ECG 17

ECG 18

ECG 19

ECG 20

ECG 21

ECG 22

ECG 23

ECG 24

ECG 25

ECG 26

ECG 27

ECG 28

ECG 29

ECG 30
ECG 31

ECG 32

ECG 33

ECG 34

ECG 35

ECG 36

ECG 37

ECG 38

ECG 39

ECG 40

ECG 41

ECG 42

ECG 43

ECG 44
ECG 45

ECG 46

ECG 47

ECG 48

ECG 49

ECG 50

ECG 51

ECG 52

ECG 53

ECG 54

ECG 55

ECG 56

ECG 57

ECG 58
ECG 59

ECG 60

ECG 61

ECG 62

ECG 63

ECG 64

ECG 65

ECG 66

ECG 67

ECG 68

ECG 69

ECG 70

ECG 71

ECG 72
ECG 73

ECG 74

ECG 75
Part 2 More challenging ECGs

ECG 76

ECG 77

ECG 78

ECG 79

ECG 80

ECG 81

ECG 82

ECG 83

ECG 84

ECG 85
ECG 86

ECG 87

ECG 88

ECG 89

ECG 90

ECG 91

ECG 92

ECG 93

ECG 94

ECG 95

ECG 96

ECG 97

ECG 98

ECG 99
ECG 100

ECG 101

ECG 102

ECG 103

ECG 104

ECG 105

ECG 106

ECG 107

ECG 108

ECG 109

ECG 110

ECG 111

ECG 112

ECG 113
ECG 114

ECG 115

ECG 116

ECG 117

ECG 118

ECG 119

ECG 120

ECG 121

ECG 122

ECG 123

ECG 124

ECG 125

ECG 126

ECG 127
ECG 128

ECG 129

ECG 130

ECG 131

ECG 132

ECG 133

ECG 134

ECG 135

ECG 136

ECG 137

ECG 138

ECG 139

ECG 140

ECG 141
ECG 142

ECG 143

ECG 144

ECG 145

ECG 146

ECG 147

ECG 148

ECG 149

ECG 150

Index
Copyright

© 2019 Elsevier Ltd. All rights reserved.

First edition 1997

Second edition 2003
Third edition 2008
Fourth edition 2013
Fifth edition 2019

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How to use this book
Part 1 Everyday ECGs
The 75 ECGs in this section are examples of those commonly seen in
clinical practice. There are several examples of the most important
abnormalities, together with examples of common variations of
normality. Anyone who has read The ECG Made Easy, 9th edition
(Elsevier, 2019) should be able to interpret these ECGs correctly.
Part 2 More Challenging ECGs
The 75 ECGs in this section are more challenging and include ECG
patterns seen less often, but anyone who has read The ECG Made
Practical, 7th edition (Elsevier, 2019) should be able to interpret them.

Further Reading
These symbols indicate cross-references to useful information in
The ECG Made Easy, 9th edition (Elsevier, 2019) and The ECG Made
Practical, 7th edition (Elsevier, 2019).
Preface
Learning about ECG interpretation from books such as The ECG Made
Easy or The ECG Made Practical (the previous editions of which were
called The ECG in Practice) is fine so far as it goes, but it never goes far
enough. As with most of medicine there is no substitute for
experience, and to make the best use of the ECG there is no substitute
for reviewing large numbers of them. ECGs need to be interpreted in
the context of the patient from whom they were recorded. You need to
learn to appreciate the variations of normality and of the patterns
associated with different diseases, and to think about how the ECG
can help patient management.
150 ECG Cases is the fifth edition of 150 ECG Problems. We have
changed the title to emphasize the importance of relating an ECG to
the patient from whom it was recorded: these 150 records came from
real patients, and at the time of recording were essential for the
diagnosis and management of real patients. The aim of the book is the
same as in the previous editions: it allows the inclusion of a lot more
ECGs than is possible in The ECG Made Easy and The ECG Made
Practical, and it is designed for the reader to improve his or her
understanding of ECGs by testing recognition skills. Some 10% of the
ECGs are new compared with the previous edition.
We have divided the book into two parts. The first part includes 75
ECGs that are commonly seen, and we have called this section
‘Everyday ECGs’ because these are the ECG patterns that crop up
frequently in the Accident & Emergency department or the outpatient
clinic. We have included several examples of ECGs from patients with
common problems, such as myocardial infarction. Those who have
read The ECG Made Easy should be able to recognize most of these
ECGs. The second part of the book, which we have called ‘More
challenging ECGs’ includes records seen less often, some of which
could be described as ‘difficult’ – and in some the reader may disagree
with our interpretation. But on the whole, anyone who has read The
ECG Made Practical should get most of the ECGs in Part 2 right.
JH, DA, JH
Introduction: making the most of
the ECG
Recording and reporting an ECG should never be an end in itself. The
ECG is a basic and valuable tool in the investigation of cardiac
problems, and it can be helpful in the case of non-cardiac problems,
too, but it must always be viewed in the context of the patient from
whom the record came. The ECG must never be a substitute for taking
a proper medical history and carrying out a careful physical
examination. Because it is simple, harmless and cheap, the ECG is
usually the first investigation in a patient with possible cardiac
disease, and it may be followed by the plain chest X-ray, the
echocardiogram, radionuclide studies, computed tomography (CT),
magnetic resonance imaging (MRI), and cardiac catheterization and
angiography – but none of these are substitutes. The ECG, a recording
of the electrical activity of the heart, gives information that can be
obtained in no other way. However, even though it is irreplaceable, it
is not infallible.
ECGs are recorded from a wide variety of patients, in an attempt to
help with a wide variety of possible diagnoses. An ECG is frequently
recorded in the course of ‘health screening’, but here it must be
regarded with considerable caution. It cannot be assumed that
individuals who present themselves for screening are asymptomatic –
the process may be being used as a substitute for a consultation with a
doctor. The ECG itself may cause difficulties of interpretation, for
there are a dozen or more normal variants. Minor abnormalities, such
as non-specific ST segment or T wave changes, will have diagnostic
and prognostic significance if the individual has symptoms that may
be cardiac in origin, but these changes can be of no importance in
totally healthy people. It is rare for an ECG to demonstrate anything
of importance in a totally healthy individual, although in athletes the
detection of abnormalities suggesting asymptomatic hypertrophic
cardiomyopathy is important.
In patients with chest pain, the ECG is important but sometimes
misleading. It is essential to remember that the ECG can remain
normal for some hours after the onset of a myocardial infarction. Too
often patients are sent home from an A&E department because their
ECG is normal, despite a reasonably convincing story of ischaemic
chest pain. Under such circumstances the ECG should be repeated
several times to see if changes are appearing, and patient management
should depend on the plasma troponin level rather than on the ECG.
Nevertheless, the ECG is important for deciding treatment in a patient
with chest pain, for the management of a patient with myocardial
infarction with ST segment elevation is quite different from that of a
patient whose ECG shows a non-ST segment elevation infarction.
Patients with intermittent chest pain that could be angina frequently
have completely normal ECGs at rest – and then the exercise test can
be valuable. The exercise test is to some extent being replaced by
myocardial perfusion scanning for the diagnosis of coronary disease
because its predictive accuracy depends on the likelihood of the
patient having angina, because there can be false negative or false
positive results, and because exercise tests are sometimes unreliable in
women. Remember that an exercise test is safe, but not totally safe,
because arrhythmias (including ventricular fibrillation) may be
induced. Nevertheless, the exercise test has the great advantage of
showing a patient's exercise tolerance, and also showing what limits
his capability.
The ECG also has a role in the investigation of patients with
breathlessness, for it can show changes associated with heart disease
(e.g. an old myocardial infarction) or with chronic chest disease.
Evidence of left ventricular hypertrophy may point to hypertension,
mitral regurgitation or aortic stenosis or regurgitation, and right
ventricular hypertrophy may be the result of pulmonary emboli or
mitral stenosis – however, all of these should have been detected
during the examination of the patient. The ECG is not a good tool for
grading the hypertrophy of the different heart chambers. It is
particularly important to remember that the ECG cannot demonstrate
heart failure: it may suggest a condition that may cause heart failure,
but it is impossible to determine from an ECG whether or not a
patient is in heart failure. However, in the presence of a completely
normal ECG, heart failure is certainly unlikely.
There are characteristic ECG appearances in several conditions that
are not primarily cardiac – for example with severe electrolyte
derangement. ECG monitoring is not an acceptable way of following
electrolyte changes in conditions such as diabetic ketoacidosis, but at
least any abnormalities may prompt the appropriate biochemical tests.
The ECG has, however, become important in the development of new
drugs, for any drug that causes QT prolongation – and this is by no
means uncommon – may cause sudden death due to ventricular
tachycardia.
It is in the investigation and management of patients with possible
arrhythmias that the ECG is of paramount importance. Patients may
complain of palpitations or dizziness and syncope as a result of
rhythm disturbances, and there is no way of identifying these with
certainty other than with an ECG. Dizziness and syncope can be the
result of rhythms that are either too fast or too slow for an effective
cardiac output, or of slow rhythms associated with disorders of
conduction. There may be little in the patient's history to point
specifically to a cardiac problem when dizziness or collapse is the
main symptom, but an appropriately abnormal ECG may
immediately point to the right diagnosis. When a patient complains of
palpitations there is a clearly a heart problem of some sort, and it is
usually possible to come close to a diagnosis by taking a careful
history – the patient with extrasystoles will describe the heart
‘jumping out of the chest’ or something equally unlikely, and the
problem will be worse when lying down at night, and after smoking
and alcohol. The patient with a true paroxysmal tachycardia will
describe the sudden onset (and sometimes the sudden cessation) of
the rapid heartbeat, and if the attack is associated with chest pain,