cg_03.

indd II

ECG
in 10 Days
David R. Ferry, MD, FACC
Chief, Cardiology Section
Loma Linda VA Healthcare System
Associate Professor of Medicine
Loma Linda University School of Medicine
Loma Linda, California

NEW YORK CHICAGO SAN FRANCISCO

LISBON LONDON MADRID MEXICO CITY
MILAN
NEW DELHI
SAN JUAN
S EOUL S INGAPORE S YDNEY TORONTO

21.04.2009 13:09:4

cg_03.indd III

10-
.
2- ,


. .

2009

21.04.2009 13:09:4

cg_03.indd IV

612.172.4
54.101
43

43

. .
. 10- / . ; . .
. . . . 2- ., . . .:
, 2009. 628 .: .
10- ,
, ,
.
.

.
.
.

ISBN 978-5-98811-112-2 (.)

ISBN 978-0-07-146562-6 (.)

2007 by McGraw-Hill Companies, Inc.

, , 2008

21.04.2009 13:09:4

cg_03.indd V

Table
of Contents

1.
2.

VI
VIII
IX
X
1

37

3.

- -

94

4.

151

5.

reentry

194

6.

246

7.

287

333

379

444

484

8.
9.
10.

21.04.2009 13:09:4

cg_03.indd VI

, 2 , 10 ,
- . , . 4 10 15 . ,
,
- ,
.
.
, ,
,
. : -,
, , .
, McGraw-Hill .
. , , , .
20 . 29 100
, 280 . ,
. ,
,
. 12 , . .
. , , .
,
, .

VI

21.04.2009 13:09:4

cg_03.indd VII

,
. Apple Macintosh G5, Adobe PhotoShop CS2
Wacom graphics tablet.
600 , .
, , ,
.

. ,

VII

21.04.2009 13:09:4

cg_03.indd VIII

, , , , , , . , ,
. -
, , , , . , . , . McGraw-Hill
- ITC
, . , , , - .
- . .

VIII

21.04.2009 13:09:4

cg_03.indd IX

. , . 5 8.
, . , . 100
, .
! , 1, .
:
, , .
,
. . , :
david.ferry@med.va.gov

IX

21.04.2009 13:09:4

cg_03.indd b:2

. 10-

Left Atrium

A-
SA node

Right Atrium

Left
Bundle
Branch

Intra-atrial Fibers

Left Anterior
Fascicle

Left Posterior
Fascicle

A-
AV Node
of His
Bundle

Left Ventricle

h
e Branc

Right Bundl
cle

Right Ventri

() .
1. A- .
2. - :
a. , .
. , , , .
.
1. .
2. .
3. .

III. ().
A. .
.

.
,
, .
.
1. .
2. PR - .
3. QRS .
4. .
5. U .

21.04.2009 13:09:4

cg_03.indd b:3

1.

QRS duration

QRS

QRS
QRS Complex

ST segmentST

T wave T

P wave

U wave U

PR
PR interval

QT interval QT

. D.
.
The
ECG
paper
1. 1.

on

1
The
ECG is recorded
moving paper
ruled
at 1 mm
intervals
with
darker

5
lines every
mm. 5 .

2. 2.

25 /,

At the standard
paper
speed of 25 mm/sec,
each
I mm
horizontally 3.

represents

40 ,

5
200 .
40 msec
and
each 5 mm
interval
200msec.

10 each

1
.
3.In
the vertical
dimension,
10 mm represents
0.1 mv of electrical

potential.

40

40 msec

200msec

200

1000

1000 msec

1
1.0 mv

IV.

The standard ECG leads

IV. .
. A.

There
are six
standard leads
(the limb(
leads)
that depict
cardiac ),
.

electrical
events from
six angles
in the frontal
or vertical
plane.
.
B.
There
are six
precordial
leads (the
chest leads)
that
depict electrical
,

events in .
the horizontal plane.

21.04.2009 13:09:4

cg_03.indd b:4

. 10-

ELECTROCARDIOGRAPHIC LEADS

aVR

II

aVL

III

aVF

Modified from
Electrocardiography by
Stephen Scheidt
S. Scheidt.
BasicBasic
Electrocardiography;
.

21.04.2009 13:09:4

cg_03.indd b:5

1.

V.

. P, QRS T ,
.
1. ,
, , .

05

10

20

30

45

6080

60
50

30

40

21.04.2009 13:09:4

cg_03.indd b:6

. 10-

2.

80
10

40

3.

3. The
loop
can be superimposed
on the frontal
plane axis.

a.
.

QRS I. I
.
, .

21.04.2009 13:09:4

cg_03.indd b:7

1.

I Q

I
QRS
I

aVF
0 ( ), QRS
+- I, R aVF.
I

21.04.2009 13:09:4

cg_03.indd b:8

. 10-

III,
S

III R

III
III

axis
()

B. The
electrical
is the
sum of all the
vectors in
that plane.
.
1. The normal QRS axis is between 30 and +90.

1.

the
30QRS
+90
. is normal is to examine Leads
2. An
easy
way to determine
axis
2.
,

,
I and aVF, and, if necessary, Lead II.
I VF , , II.

21.04.2009 13:09:4

cg_03.indd b:9

1.

QRS aVF,

aVF, ,

QRS

I,
I, ,

60

,
QRS aVF,

aVF, ,

QRS

I,

I, ,

60
I

21.04.2009 13:09:4

10

. 10-

QRS I,
I, ,

,

120

QRS aVF,


aVF, ,

QRS I,
I,
,

QRS
I,


I, ,

cg_03.indd b:10

220

21.04.2009 13:09:4

cg_03.indd b:11

1.

11

0 30

II
,

20

II

II

3.

.
3. Summary
and examples
of QRS axes.
Normal

Normal

Left Axis

Deviation

Right Axis

Deviation

Right Superior

Axis Deviation

Lead I

Lead aVF

aVF

Lead II II

21.04.2009 13:09:4

cg_03.indd b:12

. QRS I, aVF.

1-01

12
. 10-

21.04.2009 13:09:4

cg_03.indd b:13

. QRS I, aVF, II.

1-02

1.
13

21.04.2009 13:09:5

cg_03.indd b:17

1.
.

17

, .

C.

The chest leads are constructed similarly from the vector loop viewed in
the horizontal plane.

21.04.2009 13:09:5

cg_03.indd b:18

18

. 10-
.

.
D. The P wave axis
1. (1575) - 1. The normal P wave axis is quite restricted in its range (1575)
- .
because of the location of the SA node in the upper right corner of
2. I aVF P .

2.

the right atrium.

The P wave should obviously be upright in Leads I and aVF.

II

aVF

VI. Determining
heart.
rate
VI.

A. , ()

A. If the rhythm
is regular, the rate can be determined by the distance

.
between
complexes.
, 6 10.
B.

If the rhythm is irregular, the rate can be determined by counting the

number of beats in 6 sec and multiplying by 10.

VII. .
. :
1. .
VII. Sinus rhythm
2. .
3. A.
60 100 ./.
Sinus rhythm is defined as:
. ,
P QRS, 1.
Regularly
recurring P waves of the same morphology
.

2.
3.

B.

A normal P wave axis

A rate between 60 and 100 beats/min

In addition, if each P wave is followed by a QRS complex, then there is

normal sinus rhythm.

21.04.2009 13:09:5

cg_03.indd b:19

5
, 60 ./

6
, 50 ./

2
, 150 ./

3
, 100 ./

, 6
10 ( 9 6 , 90 ./)

4
, 100 ./

, 300 ./

1.
19

21.04.2009 13:09:5

cg_03.indd b:49

2.

.

49

QRS V1, I, V6.

1. , V1 Q I V6.
2. ,
V1 R I V6.
3. ()
(),
QRS .

QRS
I V6

I V6

I V6

I V6

010

2040

4060

6080

21.04.2009 13:10:2

cg_03.indd b:97

3. - -

97

3-013-01
DAY

II

AH V

II ( 400 )
PR, - 1- . AH V.
-.

21.04.2009 13:11:3

cg_03.indd b:107

3. - -

107

IV. -.
. , -,

-; - 1- , - 2- II -
3- ( 3-10, 3-11,
3-12).
- 2- I P PR.
( 3-13, 3-14).

-
. , -
.
-
.

V.

QRS - - ( 3-15, 3-16, 3-17,

3-18, 3-19, 3-20, 3-21, 3-22, 3-23).

21.04.2009 13:11:4

cg_03.indd b:157

4.

157

III. .

R,

ST

13-

Q

,
R,

23

Q, ST ST
,
,
T
T

1-

Q,
c R

- Q ,

R,
T

21.04.2009 13:12:5

cg_03.indd b:158

158

. 10-

IV. - ( 4-04, 4-05).

21.04.2009 13:12:5

cg_03.indd b:334

334

. 10-

V1V2, V6?

-?

RS > 100 ?

- RS
?

QRS (> 120 )

-.
1. - .
2. - 20 %
.
3. -:
. ,
.
. II, III,
aVF, V2.
. V3R .
. S5 ( )
, I .

21.04.2009 13:18:1

cg_03.indd b:335

8.

335

RS = 150

RS = 70

.
.

.
- .
- ,
.

21.04.2009 13:18:1

cg_03.indd b:466

466

. 10-

III. .

.

( ).

.

.

.
1. , .
2. ( 10-16).

.
1. , 1 .
2. ,
( 10-17).

21.04.2009 13:22:2