Goldberger's Clinical Electrocardiography A Simplified Approach 10Th Edition pdf
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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.