Clinical Arrhythmology

ANTONI BAYÉS DE LUNA Emeritus Professor of Cardiology, Universitat Autònoma de Barcelona, Barcelona; Honorary Director, Cardiology Service, Hospital de la Santa Creu i Sant Pau, Barcelona; Senior Consultant, Hospital Universitari Quirón, Barcelona, Spain ADRIAN BARANCHUK MD FACC FRCPC FCCS Professor of Medicine, Queen's University, Kingston, Ontario, Canada; Editor-in-Chief, Journal of Electrocardiology; President, International Society of Electrocardiology

Foreword by Dr. Valentin Fuster ix

Foreword by Dr. Pere Brugada i Terradellas xi

Preface xiii

Recommended General Bibliography xvii

Part I Anatomical and Electrophysiological Considerations, Clinical Aspects, and Mechanisms of Cardiac Arrhythmias 1

1 Clinical Aspects of Arrhythmias 3

Definition of Arrhythmia 3

Classification 3

Clinical Significance and Symptoms 4

The Importance of Clinical History and Physical Examination in Diagnosis and Assessment of Arrhythmias 18

The Importance of Surface ECG and Other Techniques 21

References 24

2 Anatomic and Electrophysiologic Basis 27

Anatomic Basis 27

Electrophysiologic Characteristics 34

References 51

3 Electrophysiologic Mechanisms 53

Mechanisms Responsible for Active Cardiac Arrhythmias 53

Mechanisms Leading to Passive Arrhythmias 70

References 80

Part II Diagnosis, Prognosis and Treatment of Arrhythmias 83

4 Active Supraventricular Arrhythmias 85

Premature Supraventricular Complexes 85

Sinus Tachycardia 88

Atrial Tachycardia 95

Junctional Reentrant (Reciprocating) Tachycardia 105

AV Junctional Tachycardia Due to Ectopic Focus 112

Chaotic Atrial Tachycardia 115

Atrial Fibrillation 115

Atrial Flutter 139

Supraventricular Tachyarrhythmias and Atrial Wave Morphology: Monomorphic and Polymorphic Morphology 148

Differential Diagnosis of Supraventricular Tachyarrhythmias with Regular RR Intervals and Narrow QRS 149

Electrocardiographic Diagnosis of the Paroxysmal Supraventricular Tachycardias: a Sequential Approach 151

References 155

5 Active Ventricular Arrhythmias 165

Premature Ventricular Complexes 165

Ventricular Tachycardias 174

Ventricular Flutter 200

Ventricular Fibrillation 201

References 205

6 Passive Arrhythmias 209

Escape Complex and Escape Rhythm 209

Sinus Bradycardia due to Sinus Automaticity Depression 209

Sinoatrial Block 212

Atrial Blocks 214

Atrioventricular Block 216

Ventricular Blocks 218

Cardiac Arrest 226

The Pacemaker Electrocardiography 226

Clinical, Prognostic, and Therapeutic Implications of Passive Arrhythmias 234

References 240

7 Analytical Study of an Arrhythmia 245

Determining the Presence of a Dominant Rhythm 245

Atrial Wave Analysis 245

QRS Complex Analysis 246

Atrioventricular Relationship Analysis 248

Premature Complex Analysis 249

Pause Analysis 249

Delayed Complex Analysis 249

Analysis of the P Wave and QRS‐T Complexes of Variable Morphology 249

Repetitive Arrhythmias Analysis: Bigeminal Rhythm 250

Differential Diagnosis Between Several Arrhythmias in Special Situations 252

References 255

Part III The ECG and Risk of Arrhythmias and Sudden Death in Different Heart Diseases and Situations 257

8 Ventricular Pre-Excitation 259

Concept and Types of Pre-Excitation 259

WPW-type Pre-Excitation (Type 1) 259

Atypical Pre-Excitation 268

Short PR Interval Pre-Excitation 268

References 270

9 Inherited Heart Diseases 273

Introduction 273

Cardiomyopathies 273

Specific Conduction System Involvement: Lenegre Syndrome 285

Ionic Channel Disorders in the Absence of Apparent Structural Heart Disease: Channelopathies 285

References 305

10 Other ECG Patterns of Risk 313

Severe Sinus Bradycardia 313

Third-Degree (Advanced) Interatrial Block 313

High-Risk Ventricular Block 317

Advanced Atrioventricular Block 319

The Presence of Ventricular Arrhythmias in Chronic Heart Disease Patients 321

Acquired Long QT 322

Electrical Alternans 325

Other Electrocardiographic Patterns of Risk for Sudden Death 326

Early Repolarization (ER) Pattern (J Wave) and Sudden Death 326

Risk of Serious Arrhythmias and Sudden Death in Patients with Normal or Nearly Normal ECG 329

References 331

11 Arrhythmias in Different Heart Diseases and Situations 335

Ischemic Heart Disease 335

Heart Failure 341

Valvular Heart Disease 345

Congenital Heart Disease 346

Hypertensive Heart Disease 348

Myocarditis 348

Cor Pulmonale 348

Pericardial Disease 348

Sudden Death in Other Heart Diseases 349

Sudden Infant Death Syndrome 349

Athletes 349

Alcohol Intake 351

Special Situations 351

Sudden Death in Apparently Healthy People 354

References 354

Appendix 359

Introduction 359

Calculation of Sensitivity, Specificity, and Predictive Value 359

Diagnostic Techniques 361

Therapeutic Techniques 372

Antiarrhythmic Agents 384

Classification of the Recommendations for Diagnostic and Therapeutic Procedures and Level of Evidence (AHA/ESC/ACC Guidelines) 388

References 389

Index 395