Goldberger's Clinical Electrocardiography A Simplified Approach 10Th Edition pdf
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- by: Ary L. Goldberger MD FACC
- Authors: Zachary D. Goldberger MD FACC FHRS , Alexei Shvilkin
- Pages: 385
- Language: English
- Format: PDF
- Size: 60.5 MB
- OVERVIEW
- This book is an introduction to electrocardiography written especially for medical students, house officers, and nurses. The text, which assumes no previous instruction in reading electrocardiograms (ECGs), has been widely used in entry-level courses. Frontline clinicians, including emergency medicine physicians, hospitalists, emergency medical technicians, physician assistants, and cardiology trainees wishing to review the essentials have consulted previous editions.
- A high degree of ECG “literacy” is increasingly important for those involved in acute clinical care at all levels, requiring knowledge that far exceeds simple pattern recognition and mnemonic aids. ECG interpretation is important not only as a focal point of clinical medicine but as an exemplar of critical thinking. The rigor demanded by competency in ECG analysis requires attention both to the subtlest of details and to
- Furthermore, ECG analysis is one of those unique areas in clinical medicine where you literally observe physiologic and pathophysiologic dynamics “play out” over seconds down to milliseconds. Not infrequently, bedside rapid-fire decisions are based on real-time ECG data. The alphabetic P-QRS-T-U sequence, much more than a flat graph, represents a dynamic mapping of multidimensional electrical signals literally exploding into existence (automaticity) and spreading throughout the heart (conduction) as part of the fundamental processes of activation and recovery. The ECG provides some of the most compelling and fascinating connections between basic “preclinical” sciences and the recognition and treatment of potentially life-threatening problems in outpatient and inpatient settings.
- This new, tenth edition follows the general format of the previous one. The material is divided into three sections. Part I covers the basic principles of 12-lead electrocardiography, normal ECG patterns, and the major abnormal depolarization (QRS) and repolarization (ST-T-U) patterns. Part II describes the mechanism of sinus rhythms, followed by a discussion of the major arrhythmias and conduction abnormalities associated with tachycardias and bradycardias. Part III presents more specialized material, including sudden cardiac death, pacemakers, and implantable cardioverter-defibrillators (ICDs), and it also reviews selected “marquee” topics presented from different perspectives (e.g., digitalis toxicity, sudden cardiac arrest) to add dimensionality to the earlier presentations. We make additional materials for review and further exploration available in online supplements (ExpertConsult.com).
ECG SKILL DEVELOPMENT AND
INCREASING DEMANDS FOR LITERACY
Throughout, we seek to stress the clinical applications
and implications of ECG interpretation. Each time
we mention an abnormal pattern, a clinical correlate
is introduced. Although the book is not intended as a
manual of therapeutics, we briefly discuss general principles of treatment and clinical management where relevant. Whenever possible, we have tried to put ourselves
in the position of the clinician who has to look at ECGs
without immediate specialist backup and make critical
decisions—sometimes at 3 a.m.!
In this spirit, we have tried to approach ECGs in
terms of a rational, simple differential diagnosis based
on pathophysiology, rather than through the tedium
of rote memorization. It is reassuring to discover that
the number of possible arrhythmias that can produce
a resting heart rate of more than 150 beats or more per
minute is limited to just a handful of choices. Only three
basic ECG patterns are observed during most cardiac
arrests. Similarly, only a limited number of conditions
cause low-voltage patterns, abnormally wide QRS complexes, ST segment elevations, and so forth.
ADDRESSING “THREE AND A HALF” KEY
CLINICAL QUESTIONS
In approaching any ECG, readers should get in the
habit of posing “three and a half ” essential queries:
What does the ECG show and what else could it be?
What are the possible causes of the waveform pattern or patterns? What, if anything, should be done about
the finding(s)?
Most basic and intermediate-level 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 issues must always be addressed
as part of answering the initial diagnostic question:
What is the differential diagnosis? (“What else could it
be?”) Are you sure that the ECG actually shows atrial
fibrillation and not another “look-alike pattern,” such as
multifocal atrial tachycardia (MAT), sinus rhythm with
atrial premature beats, atrial flutter with variable block,
or even an artifact resulting, for example, from parkinsonian tremor or a noisy baseline?
“What could have caused the arrhythmia?” is the
question framing the next set of considerations. Is the
atrial fibrillation associated with valvular or nonvalvular disease? If nonvalvular, is it related to hypertension, cardiomyopathy, coronary disease, advanced
age, hyperthyroidism, or other factors, singly or in
combination? On a deeper level are issues concerning
the most basic electrophysiologic mechanisms. With
atrial fibrillation, these mechanisms are still being
worked out and involve a complex interplay of factors
including abnormal pulmonary vein automaticity,
micro-reentrant loops (wavelets) in the atria, inflammation and fibrosis (“atriopathy”), and autonomic
perturbations
Finally, deciding on treatment and follow-up (“What
are the therapeutic options and what is the best course
to do choose in this case?”) depends in an essential way
on answers to the questions posed above, with the ultimate goal of delivering the highest level of scientifically
informed, compassionate care.
interactions where recognition of normal and abnormal
patterns is only the starting point in patient care
The tenth edition contains updated discussions of multiple topics, including intraventricular and atrioventricular (AV) conduction disturbances, electronic pacemakers
and implantable cardioverter–defibrillators (ICDs), sudden cardiac arrest, myocardial ischemia and infarction,
takotsubo cardiomyopathy, atrial fibrillation and flutter,
drug toxicities, amyloid cardiomyopathy, and COVID-19
infection, we highlight differential diagnoses, along with
“pearls and pitfalls” in ECG interpretation. Familiarity
with the limitations as well as the uses of the ECG is essential for novices and give special attention more seasoned
clinicians. Reducing medical errors related to ECGs and
maximizing the information content of these recordings,
therefore, continue to be major themes
We also continue to give special emphasis to common points of confusion. Medical terminology (jargon)
is rife with ambiguities that cause confusion and sometimes promote miscommunication. Students of electrocardiography face a barrage of challenges. Why do we
call the “P-QRS interval” the “PR interval”? What is the
difference between ischemia and injury? What is meant
by the term “paroxysmal supraventricular tachycardia
(PSVT)” and how does it differ (if it actually does) from
“supraventricular tachycardia”? Is “complete AV heart
block” synonymous with “AV dissociation”?
I am delighted that the two coauthors on the previous two editions, Zachary D. Goldberger, MD, and
Alexei Shvilkin, MD, PhD, continue in this role on the
new tenth edition. We again thank our trainees and
colleagues for their probing and challenging questions.
Finally, we wish to express special gratitude to our families for their inspiration and encouragement.
This edition again honors the memory of two
remarkable individuals: the late Emanuel Goldberger,
MD, a pioneer in the development of electrocardiography and the inventor of the aVR, aVL, and aVF leads,
who was coauthor of the first five editions of this textbook (with ALG), and the late Blanche Goldberger, an
exceptionally gifted artist and woman of valor.
