Ambulatory

Electrocardiography
Holter Monitor Electrocardiography
Edward K. Chung

Ambulatory
Electrocardiography
Holter Monitor Electrocardiography

With 152 Electrocardiograms

Springer-Verlag New York Heidelberg Berlin

Edward K. Chung, M.D., F.A.C.P., F.A.C.C.
Professor of Medicine
Jefferson Medical College of
Thomas Jefferson University
and
Director of the Heart Station
Thomas Jefferson University Hospital
Philadelphia, PA. 19107

Library of Congress Cataloging in Publication Data

Chung, Edward K
Ambulatory electrocardiography.
Includes index.
1. Arrhythmia-Diagnosis. 2. Electrocardiography.
3. Monitoring (Hospital care) 4. Ambulatory medical
care. I. Title. II. Title: Holter monitor electro-
cardiography. [DNLM: 1. Ambulatory care. 2. Electro-
cardiography. 3. Monitoring, Physiologic. WG 140.3 C559a]
RC685.A65C45 616.1'2'0754 79-44
ISBN-13: 978-1-4612-6158-2

All rights reserved.

No part of this book may be translated or reproduced
in any form without written permission from Springer-Verlag.
© 1979 by Springer-Verlag New York Inc.
Softcover reprint of the hardcover 1st edition 1979
987 654 3 2 1
ISBN-13: 978-1-4612-6158-2 e-ISBN-13: 978-1-4612-6156-8
DOl: 10.1007/978-1-4612-6156-8
To my wife, Lisa,
and my children,
Linda and Christopher
Preface
Ambulatory (Holter monitor) electrocardiog- understand the clinical situation. Diagrams and
raphy has been one of the most essential and tables considered to be clinically pertinent are
most useful noninvasive diagnostic tools in the also shown. In some instances, the clinically
field of cardiovascular disea~e in the past decade. important electrocardiographic rhythm strips
The primary indication for ambulatory obtained in our Emergency Room and Cardiac
(Holter monitor) electrocardiography is to Clinic are illustrated. The exercise electrocardio-
document any cardiac arrhythmia, particularly grams (treadmill stress ECG testing) are in-
when the rhythm disturbance occurs transiently cluded in cases in which they are clinically
or intermittently. The Holter monitor electro- useful.
cardiography has an equally important role in In General Considerations, indications, the
the evaluation of various symptoms, such as proper approach to interpretation, and tech-
dizziness, syncope, chest pain, and palpitations, nical aspects, as well as lead systems of the
which may be related to cardiac rhythm dis- Holter monitor electrocardiography, are dis-
turbances. In addition, the Holter monitor cussed. The value of Holter monitor electro-
electrocardiography provides useful information cardiography is compared with that of the
for the diagnosis of transient myocardial is- exercise (stress) ECG test. The Appendix
chemia and the evaluation of anti-arrhythmic summarizes the material by way of 11 tables.
drug therapy as well as artificial pacemaker This book will be of particular value to all
function. primary physicians, including family physicians,
The purpose of this book is to provide emergency room physicians, internists, cardiol-
practical information regarding Holter monitor ogists, cardiology fellows, and medical resi-
electrocardiography to assist the physician in dents, as well as medical students and coronary
diagnosing and treating cardiac patients. care unit nurses.
This book presents 100 cases that illustrate The most valuable and cheerful assistance of
various cardiac rhythm problems. The actual my personal secretary, Theresa McAnally, in
case histories, with the Holter monitor electro- the preparation of this book is sincerely
cardiograms in the many different clinical cir- appreciated.
cumstances that are frequently encountered in
daily practice, are discussed. In many cases, Edward K. Chung, M.D.
12-lead electrocardiograms are included with King of Prussia, Pa.
the Holter monitor ECG tracings to better
Contents
Abbreviations xi

General Considerations 1
Introduction 3
Indications for the Use of Holter Monitor Electrocardiography 4
Value of Holter Monitor versus Exercise Electrocardiography 4
Interpretation of the Holter Monitor Electrocardiogram 5
Electrode Placement 5
The Holter Monitor Recorder 6
The Holter Monitor Scanner 6
Diary Card 7
Factors Influencing the Therapeutic Approach 7
The Therapeutic Approach to Cardiac Arrhythmias 7
Cardiac Arrhythmias Requiring Treatment 9
Malignant Ventricular Premature Contractions 10
Electrocardiographic Manifestations of the Sick Sinus Syndrome 11
Diagnostic Criteria of Bilateral Bundle Branch Block 11
Benign Ventricular Arrhythmias 12

Case Histories 13

Appendix 225
Table 1. Diary Card 227
Table 2. Indications for the Use of the Ambulatory (Holter Monitor) ECG 228
Table 3. Value of the Holter Monitor ECG versus the Exercise ECG 228
Table 4. Interpretations of the Ambulatory (Holter Monitor) ECG 228
Table 5. Factors Influencing the Therapeutic Approach 228
Table 6. The Therapeutic Approach to Cardiac Arrhythmias 228
Table 7. Cardiac Arrhythmias Requiring Treatment 228
Table 8. Malignant Ventricular Premature Contractions 229
Table 9. Electrocardiographic Manifestations of the Sick Sinus Syndrome 229
Table 10. Diagnostic Criteria of Bilateral Bundle Branch Block 229
Table 11. Benign Ventricular Arrhythmias 229

Conclusion 231

Suggested Readings 235

Index 239
Abbreviations
AF: Atrial fibrillation LAHB: Left anterior hemiblock
AP1: Atrial flutter LBBB: Left bundle branch block
AMI: Anterior myocardial LPHB: Left posterior hemiblock
infarction LVH: Left ventricular
APCs: Atrial premature hypertrophy
contractions MAT: Multifocal atrial tachycardia
APIVR: Artificial MI: Myocardial infarction
pacemaker-induced MVPS: Mitral valve prolapse
ventricular rhythm syndrome
ASMI: Anteroseptal myocardial PAT: Paroxysmal atrial
infarction tachycardia
AVC: Aberrant ventricular PVT: Paroxysmal ventricular
conduction tachycardia
BBBB: Bilateral bundle branch RBBB: Right bundle branch block
block RVH: Right ventricular
BFB: Bifascicular block hypertrophy
BTS: Brady-tachyarrhythmia SSS: Sick sinus syndrome
syndrome TFB: Trifascicular block
COPD: Chronic obstructive VP: Ventricular fibrillation
pulmonary disease VPCs: Ventricular premature
DC shock: Direct current shock contractions
DMI: Diaphragmatic myocardial VT: Ventricular tachycardia
infarction WPW syndrome: Wolff-Parkinson-White
LAH: Left atrial hypertrophy syndrome
 General
Considerations
INTRODUCTION nize the ECG changes. Another visual tool is
a line display of rate and beat-to-beat interval
The clinical application of ambulatory electro- spacing changes, which also serves to alert the
cardiography was proposed as early as 1949 by scanner to record representative strips. A most
Norman J. Holter, an experimental physicist important part of the Holter monitor system is
from Helena, Montana. He applied his tech- the patient's diary (Table 1). The patient keeps
nique and the data of radiotelemetry to electro- a record of his activities, when these activities
encephalography as well as electrocardiography are taking place, and the presence of symptoms
in humans. In the latter, the patient wears an and when they occur. The time the monitor is
85-lb transmitter strapped to his back, while turned on is recorded and the tape runs at a
the electrocardiogram (ECG) signals are trans- constant speed for 10, 12, and 24 hr, respec-
mitted to a receiver. He reported this investi- tively, depending upon the capacity of the
gative work at the Montana State Medical equipment. Therefore, it is possible to correlate
Association Meeting in August, 1949. the ECG rhythm strips with the time of symp-
In 1957, major improvements in these tech- toms by using a clock synchronized to the
niques were made, and currently, the patient monitor. When the actual ECG is reproduced
carries a miniaturized radio transmitter, and from recorded tape, the physician can correlate
data are recorded on a magnetic tape for 24 hr, the detailed rhythm and wave form with the
with the newer models. patient's activities during the period monitored
When a physician wishes to evaluate a pa- (see Table 1).
tient's cardiac rhythm during the patient's usual Indications for the use of Holter monitor
daily activities, he can utilize the technique of electrocardiography are included in Table 2.
ambulatory (Holter monitor) electrocardiog- The technique can be used to confirm such
raphy. The Holter monitor ECG has a pre- diagnoses as paroxysmal tachyarrhythmias,
cordial lead system, which is connected to a bradyarrhythmias, or A-V block. The recorder
portable electrocardiographic monitor. The can be used to identify episodes of angina or
ECG signal is recorded on magnetic tape, which an anginal equivalent by the S-T segment and
may record for 10, 12, or 24 hr. This system T wave alteration. The recorder can also be
is sensitive enough to detect not only the used to evaluate the incidence of extrasystoles
various cardiac arrhythmias but also changes in and whether they occur as group beats or with
conduction pattern and the S-T segment and T R-on-T phenomenon. Another important use
wave abnormalities. of the Holter monitor ECG is in the evaluation
The tape from the Holter recorder is played of anti-arrhythmic drug therapy. By determin-
back on a scanner. This equipment can be used ing whether the incidence of arrhythmia is de-
by a trained technician to scan a 10-hr tape creased or abolished by a given drug dose, the
recording in about 20 min. The 12- and 24-hr physician is able to assess the efficacy of his
recordings require a proportionally longer time therapy. During digitalis therapy, the Holter
to scan. This rapid scanning is performed by monitor can identify digitalis-induced arrhyth-
utilizing four basic aids to recognize cardiac mias and also indicate ventricular rate control,
rhythm and conduction abnormalities. It has especially in atrial fibrillation during various
been reported that it takes only 12 min to scan activities. For patients with artificial pace-
24-h! recordings using a new scanner manu- makers, the technique is used to evaluate the
factured by the Avionics Company. status of pacemaker function. It can also indi-
With this scanner, the ECG wave forms are cate the period of time a demand pacemaker
rapidly superimposed on an oscilloscope. The is actually pacing. This can be used to predict
scanning technician readily recognizes altera- the pacemaker's life-span. Even in an early
tion in wave form and can then play back rep- stage, a malfunctioning pacemaker can be de-
resentative strips of the ECG. In addition to tected on the Holter monitor ECG.
wave-form superimposition, the scanner has an To obtain the recording, the patient is first
audible, built-in tone, which varies with changes instructed as to the nature of the examination.
in heart rate and wave form. By sensing the He is told what activities to include and to
tone change, the technician is alerted to recog- exclude during the monitoring period. In gen-

3
4 Ambulatory Electrocardiography

eral, the patient must be advised to keep the digitalization in a patient with chronic atrial
electrodes on the recorder dry and not to touch fibrillation can be assessed by evaluating the
or displace the electrodes during the recording ventricular response, particularly during physi-
period, since this may produce a recording arti- cal activity.
fact. The patient must also be given instructions When the patient suffers anginal pain, the
on how to remove the electrodes at the end of ischemic episode can be identified on the Holter
the recording period. The patient is given a moniter ECG by identifying the S-T segment
patient's diary and instructed to keep a careful and/or T wave abnormalities when the pain
record of his activities and his symptoms and occurs. Furthermore, myocardial ischemic
their time of occurrence. He should be re- changes can be corrected with the patient's ac-
minded not to forget to return the diary when tivity even when the patient fails to recognize
he returns the recorder. The patient is also the angina.
given a list of types of activities to record; these For the patient with angina pectoris, the
include exercising, walking up and down stairs, efficacy of anti-anginal drug therapy can be
arguing, smoking, defecating, urinating, eating, evaluated by the S-T segment and/or T wave
making love and sleeping. More daily activity changes during physical activity with or with-
than usual should be clearly indicated in the out cardiac arrhythmia.
diary. He should also record the kind and Another very important role of Holter mon-
amount of medication taken, and when it was itor electrocardiography is the evaluation of
taken. artificial pacemaker function. Early stage of
malfunctioning pacemaker can be detected by
Holter monitor recording by recognizing accel-
INDICATIONS FOR THE eration (runaway pacemaker) or slowing of
USE OF HOLTER MONITOR pacemaker, irregular pacing, and a failure of
ELECTROCARDIOGRAPHY sensing and/or cardiac capture by the pace-
maker.
Table 2 summarizes the indications for the
use of ambulatory (Holter monitor) electro-
cardiography. The primary indication for its VALUE OF HOLTER MONITOR
use is, needless to say, the detection of a tran- VERSUS EXERCISE
sient or an occult cardiac arrhythmia, since ELECTROCARDIOGRAPHY
such arrhythmias are usually not detected on a
conventional 12-lead electrocardiogram. When Table 3 compares the Holter monitor ECG
an arrhythmia is detected on a Holter record- with the exercise ECG.
ing, it can be evaluated relative to the patient's The ECG obtained with the Holter monitor
activity or presenting symptoms, such as syn- as well as the exercise ECG provide valuable
cope or chest pain. Conversely, many iII- information for the detection and evaluation
defined or unexplainable symptoms, such as of cardiac arrhythmias and myocardial ische-
dizziness or weakness, can be evaluated by mia; the evaluation of such symptoms as chest
Holter monitor electrocardiography to deter- pain, dizziness, syncope, or palpitations; and
mine whether a given symptom is produced by the evaluation of the efficacy of different car-
a certain cardiac arrhythmia. It should be diac drugs.
noted, however, that there are many factors For example, Holter monitor electrocardiog-
that can produce similar, if not identical symp- raphy is much more useful in detecting cardiac
toms (e.g., dizziness, syncope), and cardiac arrhythmias than is the exercise ECG test.
arrhythmia mayor may not underly a given Myocardial ischemia, however, is evaluated by
symptom in a given individual. the exercise ECG test in more depth than by
The efficacy or toxicity of various drugs can the Holter monitor. In the evaluation of various
be evaluated in conjunction with cardiac rhythm symptoms, Holter monitor electrocardiography
disturbances. Thus, all digitalis-induced ar- and the ECG test will be utilized, depending
rhythmias can be detected even when they are upon the nature of a given symptom.
transient or intermittent. Also, the status of The exercise ECG test, of course, cannot be
 General Considerations 5

used to evaluate artificial pacemaker function, physical activity and/or symptom, particu-
but the Holter monitor can. There is a slight larly during an angina episode.
morbidity and mortality involved with the exer- 6. After these steps are followed, the clinical
cise EeG, but the Holter monitor is safe. The significance of a given arrhythmia should be
cost of these two tests is almost the same, al- indicated.
though it may be slightly higher for the Holter
monitor EeG at some institutions. When the patient is under any anti-arrhyth-
mic therapy, its efficacy and toxicity can be
evaluated. During anti-arrhythmic therapy, any
occurrence of arrhythmia should be correlated
INTERPRETATION OF THE with the administration of the anti-arrhythmic
HOLTER MONITOR agent. Digitalis-induced arrhythmias especially
ELECTROCARDIOGRAPHY should be carefully evaluated. The efficacy of
digitalis in the patient with chronic atrial fibril-
Table 4 summarizes interpretations in am- lation can be determined by observing the ven-
bulatory (Holter monitor) electrocardiography. tricular response during physical activity. The
The Holter Monitor EeG must be interpreted efficacy of other anti-arrhythmic agents (e.g.,
by a well-trained cardiologist, in particular, a quinidine, procaine amide) can be easily as-
physician who is quite familiar with every sessed by comparing the frequency under medi-
known cardiac arrhythmia. cation with the preexisting ectopic beats or
A definite procedure should be followed, for rhythm.
best results: In patients with artificial pacemakers, the
1. First, the basic underlying cardiac rhythm Holter monitor recording can distinguish be-
is described (e.g., normal sinus rhythm, tween normal function and a malfunction.
atrial fibrillation). When malfunction of the pacemaker is mani-
2. When any cardiac arrhythmia is found, its fested, the EeG finding should be precisely
precise rhythm should be described. Broad described (e.g., acceleration or slowing of pac-
descriptions, in which extrasystoles, tachy- ing, irregular pacing, or failure of sensing
arrhythmias, bradyarrhythmias, etc., are and/ or cardiac capture). When artificial pace-
mentioned without a precise rhythm being maker spikes or rhythm are not detected in
specified are of little or no use in diagnosis. patients with a demand pacemaker, this should
3. When a particular arrhythmia is found, its be mentioned, and the reason for their absence
occurrence and the patient's activity or com- described.
plaints (shown on the patient's diary card, Other findings may be included in the inter-
see Table 1) should be evaluated. When the pretation of the Holter monitor EeG. When
underlying cardiac rhythm changes from the patient has ill-defined or unexplainable
time to time, the change should be corre- symptoms, such as dizziness, weakness, or syn-
lated with the patient's activity and/or cope, these symptoms should be evaluated in
symptom. terms of a possible cardiac rhythm disturbance.
4. In cases of clinically significant cardiac ar- The efficacy of the anti-anginal drug therapy
rhythmias, such as ventricular tachycardia, can be evaluated by recognizing the S-T seg-
sick sinus syndrome, or complete A-V block, ment and/or T wave alterations, as noted
the arrhythmias must be carefully evaluated above.
in conjunction with the patient's symptoms,
such as palpitations, dizziness, syncope,
shortness of breath, and chest pain. ELECTRODE PLACEMENT
5. In addition to the various cardiac arrhyth-
mias, S-T segment alterations (depression The Holter monitor has a bipolar electrode
or elevation) and T wave changes (inver- system. This consists of three electrodes: the
sion, flattening, etc.) should be recorded. exploring (usually red), indifferent (white) ,
The S-T segment and/or T wave abnormal- and ground (green) electrodes. Two basic elec-
ities must be correlated with the patient's trode positioning systems are used, although any
6 Ambulatory Electrocardiography

suitable modification is acceptable. The general V 5 are the most useful Holter monitor leads.
application is a bipolar modification of lead The newer Holter monitor system can record
V4 or V 5 • This usually allows good analyses of and scan two channels (leads) simultaneously.
P waves, QRS complexes, the S-T segment,
and T wave abnormalities. The QRS complex
is upright in most cases when this lead place- THE HOLTER MONITOR
ment is used. In this system, the exploring elec- RECORDER
trode is placed over the fifth rib in the left
mid-clavicular line. The indifferent electrode is The Holter monitor recorder (Electrocardio-
placed high over the sternum, and the ground corder Model 445, Del Mar Avionics Dynamic
electrode is placed over the fifth rib in the right Instrumentation) has the following features:
mid-clavicular line. Placement over the bone
1. Simultaneous monitoring of two ECG leads
minimizes muscle motion and artifact. The other
2. Digital clock display with event marker for
basic lead placement is a modified V1 lead,
precise time-event-symptom correlation
which is used primarily for the cardiac rhythm
3. Patient activation of event marker to pro-
analysis, though it can record S-T and T wave
vide standardization pulses and automatic
changes. The lead V1 position usually records
ECG strip during playback
a prominent P wave and also facilitates differ-
4. Smaller size (43 in. 3 ) (recorder fits into an
entiation between right bundle branch block
inside coat pocket)
(RBBB) and left bundle branch block (LBBB)
5. Weight of recorder 1.6 lb, including bat-
configurations. In this position the exploring teries and recording tape
electrode is placed over the lower sternum, the
6. Extended battery life for 32-hr recording
indifferent electrode over the upper sternum, capability
and the ground electrode over the fifth rib in
7. Increased timing accuracy better than 1/20
the right mid-clavicular line. Before the elec-
of 1 % over 26 hr
trodes are attached, the skin should be shaved 8. Provision for 26-hr monitoring (designed
and defatted with acetone, and antiperspirant for the usual 24-hr recording)
should be applied and allowed to dry. After the
leads are securely fixed, loops of the connecting
wire from each lead should be taped to the
patient's skin to prevent a sudden tension on THE HOLTER MONITOR
the wire from disconnecting a lead. The lead SCANNER
system should then be connected to a conven-
The Holter monitor scanner (Blectrocardio-
tional BCG to verify the lead morphology and
scanner Model 660A, Del Mar Avionics
the base-line steadiness. Control recordings
Dynamic Instrumentation) has the following
should be made in the supine, sitting, and
features:
standing positions, since the configuration of
the P wave, the QRS complex and S-T seg- 1. A two-lead ECG scope display and time-
ment, andlor the T waves may change depend- documented paper write-out
ing upon the patient's position. The lead sys- 2. Displays the number of ventricular and
tem is then connected to the monitor, which supraventricular ectopic beats per hour
should be checked to confirm that the unit 3. Displays the number of pacemaker beats
contains fresh batteries and a blank magnetic per hour
tape. The time the monitor is. activated is re- 4. Displays the total number of heart beats
corded on the patient's diary and the patient per hour
can then be dismissed. The monitor may be 5. A visual display of each R-R interval
carried over the shoulder or connected to a 6. A digital time display with a precise time-
belt, depending on the make and model instru- event-symptom correlation better than 5-
ment used. sec accuracy
The most commonly used lead is lead V 5, 7. Summary report of all heart rate, S-T seg-
with single channel equipment. When two- ment, and ectopic beats, related to time
channel equipment is available, leads V 1 and 8. A 24-hr tape scan in 12 min
 General Considerations 7

9. Initiation of automatic real time ECG that produces significant symptoms (e.g., pal-
write-out by a single ventricular premature pitations, dizziness, near-syncope, syncope,
beat dyspnea, chest pain) should be treated. Even
10. Initiation of automatic real time ECG when the ECG reveals an identical finding, the
write-out by three or more ventricular or symptomatic finding requires treatment, where-
supraventricular premature beats in any as the asymptomatic one is unlikely to need
lO-sec period therapy in most clinical situations.
11. Time printed on all ECG write-outs for
precise time-event-symptom correlation Clinical circumstances: The clinical cir-
cumstances definitely influence the therapeutic
approach. For instance, ventricular arrhythmias
DIARY CARD during an early phase of acute myocardial in-
farction should be aggressively treated. Ven-
Table 1 is a photograph of an actual diary tricular premature contractions in healthy in-
card. The patient should be instructed to write dividuals, however, usually require no active
down any unusual or significant symptoms, treatment other than eliminating or modifying
such as palpitations, chest discomfort, skipped any possible etiologic factors (e.g., the exces-
heart beats, shortness of breath, dizziness, or sive use of coffee, tea, Coca-Cola, tobacco).
indigestion, noting the precise time and activ- For digitalis-induced cardiac arrhythmias, of
ity. Other pertinent information includes the course, digitalis must be discontinued imme-
patient's name, age, sex, and date; the physi- diately.
cian's name and the starting time for the re-
cording should be filled in by the technician. Mechanisms of arrhythmias: The mecha-
nism underlying the cardiac arrhythmia deter-
mines the therapeutic approach. For example,
FACTORS INFLUENCING THE paroxysmal ventricular tachycardia (PVT)
THERAPEUTIC APPROACH requires immediate treatment, whereas non-
paroxysmal ventricular (idioventricular) tach-
Various factors influence the therapeutic ap- ycardia (accelerated idioventricular rhythm) is
proach (see Table 5). usually self limiting. Similarly, ordinary VPCs
often require active treatment, whereas para-
Physician's philosophy, medical background, systole is considered benign in most cases.
and experience: Obviously, the therapeutic
approach will vary greatly depending upon the Acute versus chronic arrhythmias: By and
physician's philosophy, medical background, large, cardiac arrhythmias with acute onset re-
and experience. For example, the therapeutic quire active treatment, whereas chronic ar-
approach will differ between physicians with rhythmias often do not. The best example is
an aggressive and those with a conservative an acute arrhythmia in a patient with an acute
approach. Similarly, a physician with a good myocardial infarction, which usually requires
medical background will be able to provide immediate and aggressive treatment. In addi-
more appropriate, scientific treatment than an tion, any cardiac arrhythmia with acute onset
inexperienced physician. Needless to say, is, as a rule, symptomatic.
proper management cannot be expected when
the diagnosis of a cardiac arrhythmia is in
error. THE THERAPEUTIC APPROACH
TO CARDIAC ARRHYTHMIAS
Symptomatic versus asymptomatic condi-
tions: In most cases, such asymptomatic car- Table 6 summarizes the therapeutic approach
diac arrhythmias as ventricular premature con- to cardiac arrhythmias.
tractions (VPCs) or transient supraventricular
tachyarrhythmias are unlikely to require active Eliminate the cause if possible: The first
treatment. On the other hand, any arrhythmia therapeutic approach is to eliminate any pos-
8 Ambulatory Electrocardiography

sible etiologic factor responsible for a given current (DC) shock, digitalis, and/or qUInI-
cardiac arrhythmia. For example, various car- dine. Parenteral administration of quinidine is
diac arrhythmias, particularly VPCs, paroxys- only rarely indicated.
mal supraventricular tachycardia, etc., encoun- A new drug, disopyramide phosphate (Nor-
tered in healthy individuals can be successfully pace) ~as recently been introduced into clini-
treated by eliminating or modifying the use of cal medicine; it is primarily used to treat VPCs.
all stimulants (e.g., coffee, tea, Coca-Cola, The long-term efficacy of Norpace compared
tobacco). Again digitalis-induced arrhythmias to the older anti-arrhythmic drugs requires fur-
are best treated by discontinuation of the drug, ther investigation. Various sedatives or mild
and cardiac arrhythmias induced by electrolyte tranquilizers (e.g. Valium or Librium) may be
imbalance are best managed by correcting the valuable in anxiety-induced cardiac arrhyth-
electrolyte imbalance. mias.

Anti-arrhythmic drug therapy: Many drugs Direct current shock: In clinical emergen-
are available for the treatment of various cies, particularly ventricular tachycardia (VT)
cardiac arrhythmias. Depending upon the mech- or ventricular fibrillation (VF), DC shock is
anism(s), the direct cause of a given arrhyth- often a life-saving measure. Direct current
mia and underlying cardiac disease, the anti- shock may be considered an elective procedure
arrhythmic drug of choice will vary. For in- when restoration of sinus rhythm from various
stance, the drug of choice for paroxysmal atrial chronic ectopic tachyarrhythmias is considered,
fibrillation with rapid ventricular response is especially in chronic AF. It is best to apply DC
digitalis in most clinical situations. Ventricular shock in the Coronary Care Unit or in a room
tachyarrhythmas seen in the Emergency Room with similar facilities where continuous moni-
will best be treated by an intravenous injection toring is available.
of lidocaine (Xylocaine), especially in patients
with coronary artery disease. Similarly, intra- Artificial pacemakers: The use of an artifi-
venous lidocaine has been shown to be very cial pacemaker is primarily indicated for
effective in various supraventricular tachy- patients with symptomatic second-degree or
arrhythmias, especially atrial fibrillation CAF) complete A-V block, sick sinus syndrome
with anomalous A-V conduction in the Wolff- (SSS), and symptomatic bilateral bundle
Parkinson-White (WPW) syndrome. On the branch block (BBBB). Permanent pacing is
other hand, propranolol (Inderal) is consid- definitely indicated for Mobitz type II A-V
ered to be the drug of choice for reciprocating block and all A-V blocks due to an infra-nodal
tachycardia with normal QRS complexes in the block as well as advanced SSS. Holter monitor
WPW syndrome and in most exercise-induced electrocardiography is of great value in diag-
cardiac arrhythmias. Propranolol is also con- nosing SSS and intermittent advanced A-V
sidered the drug of choice for cardiac arrhyth- block. In addition, an artificial pacemaker is
mias with or without chest discomfort in pa- occasionally indicated for drug-resistant ecto-
tients with mitral valve prolapse syndrome pic tachyarrhythmias, particularly VT.
(MVPS). Procaine amide (Pronestyl) is pri-
marily used in long-term oral therapy for Surgery: In selected patients with refrac-
chronic ventricular arrhythmias. Parenteral ad- tory tachyarrhythmias, surgical intervention
ministration of procaine amide is now much should be considered. For example, refractory
less common because lidocaine has been found tachyarrhythmias in the WPW syndrome may
to be more effective for acute or serious ven- be treated by ligating a bypass tract. Certain
tricular tachyarrhythmias. refractory ventricular tachycardia may be abol-
Diphenylhydantoin (Dilantin) is the drug ished by coronary bypass surgery, ventricular
of choice for various digitalis-induced tachy- aneurysmectomy, etc.
arrhythmias, particularly those that are ven-
tricular in origin. The main role of quinidine Any combination of the above: Not un-
is the prevention of atrial fibrillation (AF) commonly, many cardiac arrhythmias require
following restoration of sinus rhythm by direct a combined therapeutic approach. For example,
 General Considerations 9

many patients require one anti-arrhythmic drug rhythmia component, and it is often a late
or more to prevent the recurrence of arrhyth- manifestation of the SSS.
mia following restoration of sinus rhythm by The most common indication for permanent
DC shock. Another example is the brady- artificial pacing is the SSS, and drug therapy
tachyarrhythmia syndrome (BTS), which often alone has been found to be unsatisfactory.
requires one anti-arrhythmic drug or more even Various electrocardiographic manifestations of
after artificial pacing. the SSS will be discussed later (see Table 9).

Symptomatic bilateral bundle branch block

(bifascicular and trifascicular block): In symp-
CARDIAC ARRHYTHMIAS
tomatic BBBB, there are episodes of intermit-
REQUIRING TREATMENT
tent second-degree, advanced, or complete A-V
block in the presence of a number of ECG
Table 7 summarizes the cardiac arrhythmias
abnormalities characteristic of bifascicular or
that require treatment.
trifascicular block. Under these circumstances,
a permanent pacemaker is definitely indicated.
Symptomatic arrhythmias: As a rule, symp- Bilateral bundle branch block will be discussed
tomatic cardiac arrhythmias require treatment later (see Table 10).
regardless of the underlying disorder. Common
symptoms due to cardiac arrhythmias may in- Infra-nodal A-V block: In general, A-V
clude palpitations, dizziness, near-syncope, block is divided into two major types accord-
syncope, dyspnea, and chest pain. Even when ing to the site of the A-V block; these include
the ECG findings are identical, symptomatic intra-nodal (A-V nodal) block and infra-nodal
arrhythmias often require treatment, whereas block. Intra-nodal CA-V nodal) A-V block is
asymptomatic arrhythmias usually do not. usually transient in nature and reversible, and
it is commonly produced by acute diaphrag-
Malignant ventricular arrhythmias: The matic (inferior) myocardial infarction (MI),
term "malignant ventricular arrhythmias" is digitalis intoxication, and infectious heart dis-
used to designate the clinically serious ventric- ease, such as myocarditis. Infra-nodal A-V
ular arrhythmias that require active treatment, block is usually due to permanent damage of
whereas clinically insignificant ventricular ar- the Purkinje fibers, and it is not uncommon in
rhythmias are often designated "benign ven- acute anterior ML In addition, infra-nodal A-V
tricular arrhythmias." Malignant versus benign block is often designated "idiopathic," and de-
ventricular arrhythmias are described in detail generative-sclerotic changes in the Purkinje
later (see Tables 8 and 11). system are implicated. Infra-nodal A-V block,
however, is irreversible and a permanent pace-
Sick sinus syndrome and brady-tachyarrhyth- maker is definitely indicated. The Mobitz type
mia syndrome: The SSS is characterized by II A-V block is an expression of incomplete
an inadequate impulse formation in the sinus trifascicular block (TFB); while ventricular es-
node, which leads to a marked and persistent cape (idioventricular) rhythm, due to complete
sinus bradycardia followed by a variety of ECG A-V block, is the end result of complete TFB.
abnormalities. In other words, the SSS is anal- Permanent pacing is indicated in every case of
ogous to the failure of a generator, and the Mobitz type II A-V block or complete TFB.
result of the syndrome is hypoperfusion of vital
organs, particularly the brain and the heart. Persisting, exercise-induced arrhythmias:
The SSS commonly produces dizziness, near- Various cardiac arrhythmias may be induced
syncope, syncope, congestive heart failure, pal- or abolished by physical exercise in healthy in-
pitations, and angina pectoris. Sudden death dividuals as well as in cardiac patients. But
may occur in this syndrome. The term, "brady- ventricular arrhythmias induced by mild exer-
tachyarrhythmia syndrome" (BTS) is used cise with less than 70% of the maximal pre-
when the cardiac arrhythmia consists of a dicted heart rate usually indicate significant
bradycardia component as well as a tachyar- coronary heart disease. Persisting exercise-
10 Ambulatory Electrocardiography

induced arrhythmias should be thoroughly in- with diphenylhydantoin (Dilantin) or potas-

vestigated to determine their underlying cause. sium may be indicated.
When any form of cardiac arrhythmia is con-
stantly induced by ordinary daily activities, With the R-on-T phenomenon: As de-
active treatment may be indicated in addition scribed earlier, the incidence of VF is greater
to a full investigation. By and large, proprano- when the VPCs show a very short coupling
lol (Inderal) is considered the drug of choice interval (the interval from the ectopic beat to
for the various exercise-induced cardiac ar- the QRS complex of the preceding beat of the
rhythmias. basic rhythm), which is designated the R-on-T
phenomenon. This is more commonly observed
during an early phase of acute MI. Thus, VPCs
with the R-on-T phenomenon should be aggres-
MALIGNANT VENTRICULAR sively treated. The treatment of choice here is
PREMATURE CONTRACTIONS intravenous injection of lidocaine (Xylocaine)
Table 8 summarizes the types of malignant followed by intravenous infusion.
VPCs. "Malignant ventricular premature con- Multifocal: Multifocal VPCs should be ac-
tractions" here is used to designate a clinically tively treated because more serious ventricular
serious arrhythmia that requires prompt recog- tachyarrhythmias can easily be provoked. Mul-
nition and treatment. tifocal VPCs usually occur in patients with
significant underlying organic heart disease,
Symptomatic: As a rule, symptomatic particularly coronary artery disease, and/or
VPCs require some form of treatment whatever digitalis toxicity.
their etiology. For example, in frequent VPCs
that cause palpitations or chest discomfort, the Grouped: Similarly, grouped VPCs (two
arrhythmia should be suppressed. Digitalis- or more consecutively occurring VPCs) should
induced VPCs may be abolished by simply be treated because there is a greater chance of
withholding digitalis, and when VPCs are VT or even VF developing, particularly in pa-
thought to be induced by the excessive use of tients with coronary artery disease.
coffee, tea, Coca-Cola or tobacco, the causative
Induced by mild exercise with less than sev-
agent should be eliminated. More seriously, if
enty percent of the maximal heart rate: It has
VPCs cause significant symptoms, such as dizzi-
been shown that VPCs provoked by mild exer-
ness or signs of heart failure, it must be more
aggressively treated. cise with less than 70% of the maximal heart
rate are often indicative of significant coronary
artery disease. In addition to VPCs, marked
In acute myocardial infarction: By and
S-T segment depression is usually observed dur-
large, VPCs in patients with acute myocardial
ing and/ or after exercise. Mild, exercise-
infarction or significant angina pectoris should
induced VPCs are, therefore, usually considered
be suppressed because VPCs under these cir-
to be serious clinically and they should be
cumstances may frequently lead to more serious
treated.
ventricular arrhythmias, such as VT or VF.
Ventricular premature contractions during an Persisting exercise-induced ventricular pre-
early phase (the first 72 hr) of an acute MI mature contractions: When VPCs are con-
usually exhibit other forms of malignancy, such stantly induced by ordinary daily physical ac-
as the R-on-T phenomenon, in which a VPC tivity, the underlying cause must be determined.
with a short coupling interval interrupts the T Persisting exercise-induced VPCs, as a rule,
wave of the preceding beat, which is the vul- require treatment in addition to an appropriate
nerable period of the ventricles. Other malig- medical workup. Propranolol (Inderal) is the
nancies include multifocal or grouped VPCs. drug of choice for exercise-induced arrhythmias
in most cases.
In digitalis toxicity: In the mild form of
digitalis-induced VPCs, discontinuation of the Frequent: When VPCs occur at a rate of
drug alone is sufficient. Otherwise, treatment more than 30 beats per hour, the term "fre-
 General Considerations 11

quent" VPCs is used. Although there is con- block and/or intraventricular conduction dis-
troversy as to whether frequent VPCs should turbances are relatively common in the SSS. In
be treated, many physicians still treat them these cases, the bifocal demand pacemaker is
regardless of the etiologic process. the ideal mode of pacing. Practically, however,
the demand ventricular pacemaker is the most
commonly used pacing mode in the treatment
ELECTROCARDIOGRAPHIC of the SSS.
MANIFESTATIONS OF THE In advanced cases of SSS, the cardiac rhythm
SICK SINUS SYNDROME frequently exhibits A-V junctional escape
rhythm with or without slow and unstable sinus
The SSS may be manifested by a variety of activity. The BTS is commonly a manifestation
ECG abnormalities (see Table 9). The earliest, of advanced SSS. When the patient develops
and commonest, ECG finding of the SSS is BTS, one or more anti-arrhythmic drugs may
marked and persisting sinus bradycardia (rate be required to suppress the tachyarrhythmia
below 45 beats per minute), which is often fol- component, in addition to the use of artificial
lowed by an intermittent sinus arrest or a sino- pacing. The tachyarrhythmia component in the
atrial (S-A) block. The sinus bradycardia in BTS is commonly atrial tachyarrhythmia (e.g.,
SSS is drug (atropine or isoproterenol) resist- AF, AFl, or atrial tachycardia), but it may
ant, but not drug induced. be frequent VPCs or even VT. In advanced
In the SSS, a long pause often follows an cases of the SSS, various ECG manifestations
atrial premature contraction (APC) because (described in Table 9) may occur in the same
the sinus node is abnormally suppressed by the ECG.
atrial ectopic impulse. In advanced SSS, the
cardiac rhythm is commonly AF, which may
be chronic or recurrent. In many cases of SSS,
the AF shows a slow ventricular rate because DIAGNOSTIC CRITERIA OF
of advanced A-V block, and the AF is often BILATERAL BUNDLE BRANCH
preceded or followed by a marked sinus brady- BLOCK
cardia with or without a first-degree A-V block
(P-R interval ::::"" 0.28 sec). The atrial tachy- Bilteral bundle branch block includes BFB as
arrhythmia component is most commonly AF, well as TFB; the diagnostic criteria of BBBB
but it may be atrial flutter (AFl) or atrial are summarized in Table 10.
tach ycardia ( AT) . The most common form of BBBB is a com-
When the diagnosis of SSS is equivocal, pro- bination of RBBB and left anterior hemiblock
vocative tests such as rapid atrial pacing are (LAHB) to cause BFB. A less common form
performed to determine the sinus node recov- of BFB is the combination of RBBB and
ery time. That is, the interval from the last LPHB. Needless to say, BFB is a manifesta-
pacing spike to the first sinus P wave-the tion of an incomplete BBBB, and in many
sinus node recovery time-is measured upon cases, the BBBB is incomplete. When the
abrupt termination of atrial pacing. The atrial BBBB is complete, the end result is, of course,
pacing rate may be started with 120 beats per complete A-V block (complete TFB), which
minute and the rate may be increased progres- produces ventricular escape (idioventricular)
sively by 10 beats per minute up to a pacing rhythm.
rate of 150 beats per minute. The duration of Alternating LBBB and RBBB is a rare man-
the atrial pacing is usually 2 to 4 min, and the infestation of BBBB. But not uncommonly, one
most practical pacing mode is coronary sinus may find LBBB on one occasion and RBBB
pacing. When the sinus node recovery time is on another in the same individual as a mani-
over 1500 msec, the presence of the SSS is festation of BBBB, and LBBB or RBBB asso-
confirmed. Concealed A-V conduction disturb- ciated with first- or second-degree A-V block
ance will be unmasked by rapid atrial pacing, may be due to incomplete BBBB. When dealing
and Wenckebach (Mobitz type I) A-V block with a Mobitz type II A-V block, the diagnosis
is also commonly produced. Coexisting A-V of incomplete BBBB is confirmed, and the QRS
12 Ambulatory Electrocardiography

complexes nearly always exhibit RBBB, LBBB, dividuals nearly always arise from the right
hemiblock, or BFB. ventricle. Right VPCs can be diagnosed by
It has been proposed that the presence of recognizing the negative (downward) QRS
BBBB is confirmed when the H-V interval (the complex in the right precordial leads and posi-
interval from the His bundle potential to the tive (upright) QRS complex of the ectopic
first component of the ventricular deflection on beats in the left precordial leads. Thus, right
the His bundle electrogram) is 70 msec or VPCs are considered benign in most cases.
more in the presence of RBBB or LBBB. In Conversely, the VPCs found in a diseased
many cases of incomplete BBBB, various ECG heart and/or in digitalis intoxication commonly
abnormalities may coexist, as described in originate from the left ventricle or the ventric-
Table 10. ular septum. The QRS complex of the left
VPCs is positive (upright) in the right pre-
cordial leads and negative (downward) in the
BENIGN VENTRICULAR left precordial leads. The septal VPCs produce
ARRHYTHMIAS a positive (upright) QRS complex in both the
right and the left precordial leads.
In contrast to malignant ventricular arrhyth-
mias, some ventricular arrhythmias are benign Ventricular parasystole and parasystolic
and self limiting. Benign ventricular arrhyth- ventricular tachycardia: Although ventricular
mias are summarized in Table 11. parasystole and parasystolic VT are not un-
commonly encountered in patients with organic
Occasional unifocal ventricular premature heart disease, these arrhythmias are found to
contractions: When VPCs occur at a rate of be self limiting in most cases. The usual rate
less than 30 beats per hour, and when they are of the parasystolic VT ranges from 70 to 130
unifocal in origin, they are usually considered beats per minute. No treatment is indicated.
benign. No treatment is indicated in most cases.
Non-paroxysmal ventricular tachycardia (ac-
Asymptomatic ventricular premature con- celerated idioventricular rhythm): Similarly,
tractions: Asymptomatic VPCs are unlikely non-paroxysmal VT (accelerated idioventricu-
to cause any significant alterations in hemo- lar rhythm) is also considered to be benign,
dynamics, and they are usually found in indi- since the arrhythmia is self limiting in most
viduals without demonstrable heart disease. cases. The usual rate range is between 70 and
130 beats per minute, as it is in parasystolic
Right ventricular premature contractions: VT. Both non-paroxysmal VT and parasystolic
Although there is no uniform agreement among VT are relatively common in the first 72 hr of
cardiologists, VPCs encountered in healthy in- acute MI.
Case Histories
 Case 1 / Diagnosis 15

CASE 1 1. What is the 12-lead EeG diagnosis?

2. What is the cardiac rhythm diagnosis for
A 61-year-old woman with hypertensive heart the Holter monitor EeG?
disease had been taking digoxin (0.25 mg) 3. What is the most likely underlying cause for
and hydrochlorothiazide (50 mg) daily for her arrhythmia?
several months. The Holter monitor BeG was 4. What is the therapeutic approach of choice?
obtained because she complained of palpita-
tions.
16 Ambulatory Electrocardiography

Diagnosis but there are frequent multifocal ventricular

12-lead ECG: The basic rhythm is sinus premature contractions producing ventricular
with a rate of 86 beats per minute. The diag- bigeminy.
nosis of left ventricular hypertrophy is readily Ventricular bigeminy has been considered a
made on the basis of tall R waves in leads I, hallmark of digitalis-induced arrhythmia for
aVL, V 5, and V 6, with deep S waves in leads many years. Digitalis intoxification should be
III and V 1 associated with the secondary S-T, considered as the probable cause for the devel-
T wave changes in the left precordial leads. It opment of any new cardiac arrhythmias, par-
should be noted that systemic hypertension is ticularly ventricular bigeminy during digitalis
the most common cause of left ventricular hy- therapy. Therefore, the therapeutic approach
pertrophy (LVH). In addition, left atrial hy- should be immediate discontinuation of digi-
pertrophy (LAH) is suggested. talis. When ventricular bigeminy persists fol-
lowing discontinuation of digitalis, potassium
Holter Monitor ECG: The rhythm strips or diphenylhydantoin (Dilimtin) should be
A through C are not continuous. The basic tried.
rhythm is sinus (rate: 90 beats per minute),

c
 Case 2 / Diagnosis 17

CASE 2 ing, excessive use of coffee, tea, or Coca-Cola).

A Holter monitor BCG was obtained to clarify
A 65-year-old man with no known cardiac dis- the nature of his palpitations.
ease was seen at the cardiac clinic because of
palpitations. He was not taking any drugs, and 1. What is the cardiac rhythm diagnosis?
he denied any unusual habits (e.g., heavy smok- 2. What is the drug of choice?
18 Ambulatory Electrocardiography

Diagnosis Ventricular group beats, particularly when

12-lead ECG: The basic cardiac rhythm is three or more VPCs occur consecutively and/or
sinus (rate: 90 beats per minute), but there when they are multifocal in origin, should be
are frequent ventricular premature contractions treated even if they are asymptomatic.
(VPCs) and occasional atrial premature con- For oral administration, quinidine or pro-
tractions (APCs). The remaining ECG find- cainamide (Pronestyl) are equally effective.
ings are unremarkable except for low voltage The usual oral dosage of quinidine is 300 to
of the QRS complexes and a nonspecific S-T 400 mg every 6 hr. Because of the short thera-
segment abnormality. peutic effect of procainamide, 250 to 500 mg
of the drug must be given every 3 hr. The
Holter Monitor ECG: The strips A through major disadvantage of procainamide is, ob-
D are not continuous. The basic rhythm is viously, frequent administration of the drug to
sinus (rate: 95 beats per minute), but there maintain the therapeutic blood level.
are frequent multifocal VPCs causing intermit- Less commonly, VPCs may be treated with
tent ventricular group beats (three to four con- oral disopyramide (Norpace) or propranolol
secutive VPCs). The term "ventricular group (Inderal). When there is not a clinical emer-
beats" is used when two or more (up to five) gency, intravenous administration of any anti-
VPCs occur consecutively; the term "ventricu- arrhythmic drug is unwarranted.
lar tachycardia" is used when six or more con-
secutive VPCs are observed. In addition, there
are occasional APCs.

o
 Case 3 / Diagnosis 19

CASE 3 hypertension. The Holter monitor EeG was

obtained to clarify the cause of her dizziness
A 73-year-old woman who gave a history of and near-syncope.
"heart attack" 6 mos earlier was seen in her
1. What is the 12-lead EeG diagnosis?
family physician's office because of dizziness
2. What is the cardiac rhythm diagnosis for the
and near-syncope. She was not taking any car-
Holter monitor EeG?
diac drugs, but· she was taking hydrochloro-
3. What is the treatment of choice?
thiazide (50 mg) every other day for mild
20 Ambulatory Electrocardiography

Diagnosis Holter Monitor ECG: The rhythm strips

12-lead ECG: The basic cardiac rhythm A through D are not continuous. The cardiac
is atrial fibrillation (AF), but the ventricular rhythm is AF with advanced A-V block pro-
rate is very slow (45 to 60 beats per minute) ducing a very slow ventricular rate (32 to 45
as a result of advanced (high-degree) A-V beats per minute) with occasional A-V junc-
block. The diagnosis of an old diaphragmatic tional as well as ventricular escape beats (X).
myocardial infarction (DMI) is not obvious This BCG finding is a characteristic feature of
on this ECG tracing, but she had suffered an advanced sick sinus syndrome (SSS) (see
unequivocal myocardial infarction 6 mos Table 9).
earlier, and left ventricular hypertrophy is The treatment of choice for the SSS is, ob-
strongly suggested. In addition, there are prom- viously, implantation of a permanent pace-
inent U waves (in leads V2-4) suggestive of maker.
hypokalemia.

D
 Case 4 / Diagnosis 21

CASE 4 prescribed in a dosage of 150 mg every 6 hr

for VPCs. There was no evidence of digitalis
The Holter monitor BCG was obtained on a intoxmcation. She had suffered from myocar-
65-year-old woman with coronary artery dis- dial infarction (MI) 1 yr earlier.
ease to evaluate the efficacy of disopyramide
1. What is the 12-lead ECG diagnosis?
(Norpace) for her frequent ventricular prema-
2. What is the cardiac rhythm diagnosis for
ture contractions (VPCs). She had been taking
the Holter monitor BCG?
digoxin (0.25 mg) daily for chronic atrial fib-
3. What is the treatment of choice?
rillation (AF) and congestive heart failure for
several months. Recently, oral Norpace was
22 Ambulatory Electrocardiography

Diagnosis Holter Monitor EeG: The strips A through

12-lead EeG: The underlying cardiac C are not continuous. The underlying cardiac
rhythm is AF with a ventricular rate of 100 to rhythm is AF with a well-controlled ventricular
125 beats per minute. An old diaphragmatic rate (70 to 100 beats per minute). Note the
MI is evidenced by Q waves with T wave in- intermittent left bundle branch block (LBBB)
version in leads II, II, and aVF. In addition, (arrows), which closely simulates frequent
left ventricular hypertrophy is strongly sug- VPCs with group beats. Obviously, no treat-
gested, although the S-T, T wave changes may ment is indicated for the intermittent LBBB.
be partially or totally due to the digitalis. No
VPCs are demonstrated.

c
 Case 5 / Diagnosis 23

CASE 5 Holter monitor EeG was obtained to evaluate

her heart rate response during various daily
A 53-year-old woman with known rheumatic activities.
heart disease came to the hospital because of
increasing dyspnea on exertion associated with 1. What is the cardiac rhythm diagnosis?
palpitations. She was not taking any drugs. The 2. What is the drug of choice?
24 Ambulatory Electrocardiography

Diagnosis is 1945 by Ashman as an explanation of why

. J2-lead ECG: The underlying cardiac AVC occurred following a long ventricular
rhythm is coarse atrial fibrillation (AF) with a pause. Namely, the longer the ventricular pause
ventricular rate of 85 to 100 beats per minute. preceding the coupling interval, the longer the
Otherwise, her ECG findings are unremarkable refractory period in the following beat, where-
except for a slight nonspecific T wave abnor- as the shorter the ventricular cycle preceding
mality. The coarse AF suggests left atrial hyper- the coupling interval, the shorterlthe refractory
trophy, which is common in rheumatic heart period in the following beat. The aberrantly
disease, and particularly in mitral stenosis. conducted beats (arrows) closely simulate fre-
quent VPCs with group beats, but the absence
Holter Monitor ECG: The rhythm strips of a post-ectopic pause excludes the possibility
A through E are not continuous. The cardiac of VPCs, especially in the presence of AF.
rhythm is again AF with a very rapid ventricu- That is, AVC is confirmed on the basis of two
lar response (rate: 150 to 230 beats per min- main findings-Ashman's phenomenon and the
ute) especially during physical activity. Note absence of a post-ectopic pause. It is extremely
the frequent bizarre QRS complexes (arrows) important to distinguish between AVC and
due to aberrant ventricular conduction (AVC) VPCs or short runs of ventricular tachycardia
as a result of Ashman's phenomenon. because the therapeutic approach will be
markedly different.
Ashman's phenomenon is the most common The drug of choice is, of course, digitalis.
cause of AVC. This phenomenon was described

E
 Case 6 / Diagnosis 25

CASE 6 1. What is the 12-lead BCG diagnosis?

2. What is the cardiac rhythm diagnosis for the
A 66-year-old man was examined at the Car- Holter monitor ECG?
diac Clinic because he complained of an irreg- 3. What is the treatment of choice?
ular, slow pulse associated with "weak spells."
He was not taking any drugs. He had never
been told that he had a cardiac disease.
26 Ambulatory Electrocardiography

Diagnosis cians, Wenckebach and Mobitz, both described

12-lead ECG: The cardiac rhythm is sinus this electrophysiologic phenomenon.
(rate: 95 beats per minute) with a first-degree In contrast to the Mobitz type I A-V block,
A-V block (P-R interval: 0.30 sec). There is the Mobitz type II A-V block is characterized
a slight nonspecific S-T, T wave change. Ob- by constant P-R intervals with the periodic
viously, the 12-lead ECG finding is not suffi- appearance of blocked P waves.
cient to explain the patient's complaints. There- Wenckebach A-V block is nearly always due
fore, a 24-hr Holter monitor ECG was ob- to a block at the A-V nodal region (intra-nodal
tained. block), whereas Mobitz type II A-V block rep-
resents an infra-nodal block. Wenckebach A-V
Holter Monitor ECG: The strips A through block is commonly found in digitalis intoxifica-
D are not continuous. Note the sinus P waves tion, acute diaphragmatic myoca!dial infarc-
(arrows). The patient's Holter monitor ECG tion (MI), and myocarditis, whereas Mobitz
reveals a sinus rhythm (rate: 65 beats per min- type II A-V block is either due to an acute
ute) with an intermittent Wenckebach (Mobitz anterior MI or a chronic sclerotic-degenerative
type I) A-V block and frequent ventricular change in the Purkinje system, an incomplete
premature contractions (VPCs) with group trifascicular block (incomplete bilateral bundle
beats (V). In a broad sense, this cardiac branch block) (see Table 10). When the direct
rhythm disorder is a manifestation of the brady- cause for the Wenckebach A-V block is not
tachyarrhythmia syndrome. found, the block is most likely due to a chronic
degenerative-sclerotic process in the A-V node.
Wenckebach A-V block is characterized by Symptomatic and persisting second-degree
a progressive lengthening of the P-R intervals (even Wenckebach type) A-V block requires
until a blocked P wave occurs. Since the degree permanent pacing, especially when the direct
of increment in the P-R intervals in Wencke- cause (e.g., digitalis intoxification or acute dia-
bach A-V block decreases, the ventricular phragmatic MI) is absent. When VPCs are not
cycles (R-R intervals) become progressively suppressed by artificial pacing, one or more
shorter until a blocked P wave occurs. Thus, anti-arrhythmic drugs (e.g., quinidine, procain-
the R-R interval including a blocked P wave amide) may be indicated.
is always less than two sinus P-P cycles. Mobitz type II A-V block requires perma-
Wenckebach A-V block has another name- nent pacing whether the patient is symptomatic
Mobitz type I A-V block because two physi- or not, since the block is irreversible.
 Case 6 / Diagnosis 27

D
 Case 7 / Diagnosis 29

CASE' 7 sonal habits (e.g., heavy smoking, excessive use

of coffee, or Coca-Cola). Her physical findings
The Holter monitor BCG was obtained from were unremarkable.
a 79-year-old woman who complained of fre-
1. What is the cardiac rhythm diagnosis?
quent episodes of palpitations. She denied any
2. What is the treatment of choice?
known cardiac disease, and she was not taking
any drugs. She also denied any unusual per-
30 Ambulatory Electrocardiography

Diagnosis When there is no sign of congestive heart

12-lead ECG: The cardiac rhythm is sinus failure or significant obstructive pulmonary
with a rate of 88 beats per minute. Her 12-lead disease, small oral doses of propranolol (10 to
EeG is within nortnallimits, except for a slight 20 mg, three to four times daily) will be the
nonspecific S-T segment abnormality. drug of choice. Digitalis, however, will be the
drug of choice when there is any sign of con-
Holter Monitor ECG: Strips A and Bare gestive heart failure associated with paroxysmal
not continuous. The cardiac rhythm shows atrial tachycardia. Quinidine may be tried (0.3
paroxysmal supraventricular (most likely atrial) to 0.4 gm every 6 hr orally) instead of pro-
tachycardia with a rate of 200 beats per min- pranolol (lnderal).
ute. Note the frequent aberrant ventricular con-
duction (early part of strip A).

B
 Case 8 / Diagnosis 31

CASE 8 was not sufficient to explain his dizziness.

Therefore, the Holter monitor BeG was ob-
A 73-year-old man was seen in the cardiol- tained. He was not taking any drugs.
ogist's office for the evaluation of dizziness.
1. What is the 12-lead BeG diagnosis?
The physical examination showed a normal
2. What is the cardiac rhythm diagnosis for
elderly male without demonstrable heart dis-
the Holter monitor BeG?
ease or cerebrovascular disorder. His 12-lead
3. What is the treatment of choice?
BeG was definitely abnormal, but the finding
32 Ambulatory Electrocardiography

Diagnosis that a very long pause follows the termination

12-lead ECG: The underlying cardiac of PAT (strip A). This finding is a reliable
rhythm is sinus bradycardia (rate: 50 beats per sign of an abnormally prolonged sinus node
minute), with occasional atrial premature con- recovery time. Thus, a diagnosis of the sick
tractions (APCs). The diagnosis of right bun- sinus syndrome (SSS) can be made. The oc-
dle branch block (RBBB) is obvious on the currence of ventricular escape beats (X) fol-
basis of an RR' pattern of the QRS complexes lowing a pause is indirect evidence of a diseased
in leads V1 and V 2, with slurred and deep S A-V node because the expected A-V junctional
waves in leads I, aVL, and V4-6. In addition, escape beats fail to appear. It is well known
left ventricular hypertrophy is suggested by vol- that the SSS is often associated with a diseased
tage criteria. A-V node, since the same process often in-
volves the sinus node as well as the A-V node.
Holter Monitor ECG: Strips A through C The Holter monitor BCG findings on this
are not continuous. The P waves are not clearly patient show bradytachyarrhythmia syndrome,
discernible (a not uncommon finding in elderly which is a manifestation of advanced SSS (see
individuals), but the cardiac rhythm is most Table 9). The treatment of choice is implanta-
likely sinus, from the finding on the 12-lead tion of a permanent pacemaker. When atrial
BCG. There are frequent APCs, with atrial tachycardia recurs following artificial pacing,
group beats and paroxysmal atrial tachycardia one or more anti-arrhythmic drugs (e.g., pro-
(PAT). Note also the occasional ventricular pranolol, quinidine, digitalis) may be indicated.
escape beats (X). In addition, it is interesting

c
 Case 9 / Diagnosis 33

CASE 9 Holter monitor ECG was obtained to evaluate

pacemaker function because she complained
The Holter monitor ECG was obtained from a of palpitations. She was not taking any drugs.
67-year-old woman with coronary artery dis-
ease who had a permanent artificial pacemaker 1. What is the cardiac rhythm diagnosis?
2. What is the treatment of choice?
(demand unit) implantation 2 yr earlier. The
34 Ambulatory Electrocardiography

Diagnosis cates an abnormal sensing mechanism, a sign

12-lead ECG: The cardiac rhythm is a of malfunction. In addition, the pacing cycle is
demand pacemaker-induced ventricular rhythm irregular, another sign of malfunction. Note
(rate: 73 beats per minute) with an occasional the artificial pacemaker spikes without ventric-
sinus beat (the fifth and the twelfth). The evi- ular capture (arrows).
dence of an old diaphragmatic myocardial in- Needless to say, the treatment of choice for
farction is shown only in lead aVF. The artifi- the malfunctioning artificial pacemaker is im-
cial pacemaker is functioning normally, as seen mediate replacement wtih a new unit.
from the 12-lead EeG findings.
A malfunctioning pacemaker may produce
Holter Monitor ECG: Strips A through E the following:
are not continuous. The artificial pacemaker
1. Acceleration of pacing ("runaway pace-
functions normally in the strip A, but in the
m,aker")
remaining strips (B through E) a malfunction
2. Slowing of pacing
of the demand ventricular pacemaker can be
3. Irregular pacing
seen. A demand pacemaker functions as a
4. Failure of sensing
fixed-rate ventricular pacemaker. Note that the
5. Failure of cardiac capture
patient's own sinus rhythm (S) competes with
6. Any combination of the above
the pacemaker rhythm (P). This finding indi-

E
 Case 10/ Diagnosis 35

CASE 10 mal, but the abnormality was not sufficient to

explain his complaints. Therefore, a Holter
A 67-year-old hypertensive male was seen at monitor BCG was ordered.
the Cardiac Clinic for the evaluation of dizzi-
1. What is the 12-lead BCG diagnosis?
ness and near-syncope. He has been taking
2. What is the Holter monitor BCG diagnosis?
methyldopa (Aldomet), 500 mg twice daily.
3. What is the treatment of choice?
His 12-lead BCG finding was definitely abnor-
36 Ambulatory Electrocardiography

Diagnosis rhythm shows a marked sinus bradycardia with

12-lead ECG: The cardiac rhythm is sinus a rate of 42 beats per minute. This finding may
bradycardia with a rate of 53 beats per minute. be responsible for the dizziness or even the
The diagnosis of right bundle branch block is near-syncope.
obvious on the basis of the RR' in leads V l - 2 Discontinuation of methyldopa eliminated
with slurred and deep S waves in many leads, his complaints, and the sinus rate progressively
particularly leads V4-6 with broad QRS com- increased thereafter. It is well known that one
plexes. The above findings are not sufficient to of the common side effects of this drug is
explain his dizziness or near-syncope. marked sinus bradycardia. On rare occasions,
large doses of mythyldopa may cause an A-V
Holter Monitor ECG: The rhythm strips block of various degrees including complete
A through C are not continuous. The cardiac (third degree) A-V block.

c
 Case II/Diagnosis 37

CASE 11 usual habits, such as excessive intake of coffee

or tea or heavy smoking.
A 71-year-old man was examined for the evalu-
ation of his irregular and slow pulse. He was 1. What is the cardiac rhythm diagnosis?
not taking any drugs, and he denied any un- 2. What is the drug of choice?
38 Ambulatory Electrocardiography

Diagnosis Holter Monitor ECG: Strips A through E

Cardiac Rhythm Strips (leads V 1 , II, and are not continuous. The P waves are not clearly
V s): The basic cardiac rhythm is sinus (rate: visible, but the mechanism is most likely sinus
73 beats per minute), but there are frequent from the finding shown on the 3-lead rhythm
atrial ectopic beats (arrows); and some of the strips. The Holter monitor ECG shows sinus
ectopic beats are blocked (the first ectopic P rhythm (rate: 70 beats per minute) with atrial
wave). Frequent atrial ectopic beats closely parasystole (many parasystolic P waves are
simulate atrial premature contractions, but the blocked), and frequent multifocal VPCs with
diagnosis of atrial parasystole can be made on ventricular group beats.
the basis of varying coupling intervals and con- Although atrial parasystole is considered
stant shortest interectopic intervals. In addi- benign and self-limiting, multifocal VPCs with
tion, there are occasional ventricular premature group beats should be treated (see Table 8).
contractions (VPCs) (X). It is interesting to The drug of choice will be either oral quinidine
note that the VPCs follow the atrial parasys- (0.3 to 0.4 gm every 6 hr) or procainamide
tolic P waves. This finding may erroneously be (250 to 500 mg every 3 to 4 hr). Propranolol
diagnosed as atrial parasytole with aberrant or Norpace may be tried if these drugs are not
ventricular conduction. effective.

E
 Case 12 / Diagnosis 39

CASE 12 lead EeG finding was definitely abnormal, but

the findings were not sufficient to explain his
A 78-year-old man with hypertensive heart near-syncope.
disease was seen in the cardiologist's office for
1. What is the 12-1ead EeG diagnosis?
the evaluation of his near-syncope. He was not
2. What is the Holter monitor EeG diagnosis?
taking any drugs except hydrochlorothiazide
3. What is the treatment of choice?
(25 mg daily) for mild hypertension. His 12-
40 Ambulatory Electrocardiography

Diagnosis appear) is indirect evidence in support of a

12-lead ECG: The cardiac rhythm is atrial diseased A-V node. The patient's Holter moni-
flutter-fibrillation (AFl-AF) with a ventricular tor EeG finding is a good example of advanced
rate of 60 to 80 beats per minute. It is obvious sick sinus syndrome (SSS) (see Table 9). As
to recognize RBBB. In addition, left ventricu- described, the SSS often coexists with a diseased
lar hypertrophy is strongly suggested. A-V node because the same disease process,
sclerotic-degenerative changes, involves the
Holter Monitor ECG: Strips A through D sinus node as well as the A-V node.
are not continuous. Again, the underlying car- The treatment of choice for the SSS is, of
diac rhythm is atrial flutter-fibrillation (AFI- course, a permanent pacemaker. Here, oral
AF) but there are frequent ventricular escape digitalis or propranolol may be required if the
(idioventricular) beats (X) as a result of the patient develops a rapid ventricular response
advanced A-V block. This finding (a failure during physical exercise after artificial pacing.
of the expected A-V junctional escape beats to

o
 Case 13 / Diagnosis 41

CASE 13 abnormality was not sufficient to explain her

symptoms. She was not taking any drugs.
An 82-year-old woman was seen in the Emer-
1. What is the 12-lead EeG finding?
gency Room because of a "history of fainting."
2. What is the Holter monitor EeG finding?
Physical examination failed to demonstrate any
3. What is the treatment of choice?
possible cause of her complaint. Her 12-lead
EeG finding was definitely abnormal, but the
42 Ambulatory Electrocardiography

Diagnosis sinus, from the finding on the 12-lead EeG.

12-1ead ECG: The cardiac rhythm is a The Holter monitor EeG shows a sinus with
normal sinus rhythm with a rate of 60 beats a paroxysmal supraventricular (probable atrial)
per minute. The diagnosis of left bundle branch tachycardia (rate: 140 beats per minute) ,
block is obvious on the basis of broad QRS which may be sufficient to cause dizziness, near-
complexes showing a RR' pattern in leads I, syncope, or even syncope in elderly individuals
aVL, and V4-6, with secondary S-T, T wave with a poor cardiac reserve.
changes and deep S waves in leads V1-3. This The first drug of choice will be oral pro-
EeG finding does not explain her symptoms, pranolol (Inderal) (10 to 20 mg) three to four
a history of fainting. Therefore, a Holter moni- times daily, providing that there is no con-
tor EeG was obtained. traindication (e.g., congestive heart failure,
chronic obstructive pulmonary disease). If In-
Holter Monitor ECG: Strips A through D deral cannot be given for any reason, oral
are not continuous. The P waves are not clearly quinidine (0.3 to 0.4 gm, every 6 hr) should
discernible, but the mechanism is most likely be tried.

D
 Case 14/ Diagnosis 43

CASE 14 sublingual nitroglycerin had always been effec-

tive. He was taking no other drug.
The Holter monitor ECG was obtained from
1. What is the 12-lead ECG diagnosis?
a 70-year-old man with coronary heart disease
2. What is the Holter monitor BCG diagnosis?
because of his complaints of dizziness. He had
3. What is the treatment of choice?
been suffering from angina pectoris for which
44 Ambulatory Electrocardiography

Diagnosis tachycardia (VT) (arrows) at a rate of 120

12-1ead ECG: The cardiac rhythm is sinus beats per minute. The ventricular ectopic beats
bradycardia with a rate of 48 beats per minute. (X) show markedly varying coupling intervals,
The significant EeG abnormality on this trac- but the diagnosis of ventricular parasytole can-
ing is the presence of tall T waves in leads V H, not be entertained with certainty because a
with inverted T waves in many leads indicating direct parasystolic cycle (the shortest interec-
diffuse myocardial ischemia. It should be noted topic interval) was not found.
that the tall T waves in leads V H represent The Holter monitor EeG diagnosis on this
posterior myocardial ischemia. These EeG patient is the brady-tachyarrhythmia syndrome
findings, however, are not sufficient to explain (BTS), which consists of a marked sinus brady-
his dizziness. Therefore, a Holter monitor EeG cardia and frequent ventricular ectopic beats,
was obtained. with intermittent VT. As mentioned, the BTS
is a manifestation of advanced sick sinus syn-
Holter Monitor ECG: Strips A through D drome for which permanent artificial pace-
are not continuous. The basic cardiac rhythm maker implantation is the treatment of choice.
is marked sinus bradycardia, but there are fre- One or more anti-arrhythmic drugs (quinidine
quent multifocal ventricular ectopic beats (X; or procainamide) may be required if ventricu-
arrows) causing an intermittent ventricular lar ectopy is not suppressed by artificial pacing.

D
 Case 15/ Diagnosis 45

CASE 15 other drugs. On physical examination, there

was no evidence of congestive heart failure and
A 72-year-old hypertensive man was seen at the only significant positive finding was an oc-
the Cardiac Clinic for the evaluation of palpi- casional extrasystole on auscultation. He de-
tations. During a careful history taking, he ad- nied any unusual habits (e.g., excessive use of
mitted that he had suffered severe chest pain coffee or tea; heavy smoking).
6 mos earlier, but he failed to seek medical
attention at that time. He also recalled an occa- 1. What is the 12-lead ECG diagnosis?
sional anginal pain in the past. He was taking 2. What is the Holter monitor ECG diagnosis?
hydrochlorothiazide (50 mg daily) for long- 3. What is the drug of choice?
standing hypertension. He was not taking any
46 Ambulatory Electrocardiography

Diagnosis His ventricular arrhythmia required imme-

12-1ead ECG: The basic cardiac rhythm is diate treatment. In the presence of a long-
sinus (rate: 92 beats per minute), but there standing systemic hypertension and angina pec-
are occasional ventricular premature contrac- toris, propranolol (lnderal) should be the first
tions (VPCs). Left ventricular hypertrophy is choice of drug because it would be of benefit
strongly suggested, although typical secondary for the patient's ventricular arrhythmia and his
S-T, T wave change in the left precordial leads hypertension, as well as his angina. Oral pro-
is not obvious. In addition, an old diaphrag- pranolol should be tried (10 to 40 mg, three
matic myocardial infarction is a good possibil- to four times daily). If propranolol is shown
ity, on the basis of small q waves in leads II, to be ineffective, oral quinidine (0.3 to 0.4
III, and aVF, particularly considering his his- gm every 6 hr), or procainamide (250 to 500
tory of chest pain 6 mos earlier. mg every 3 to 4 hr), should be tried as an
anti-arrhythmic drug.
Holter Monitor ECG: The rhythm strips Malignant ventricular arrhythmias (see
A through C are not continuous. The under- Table 8), especially in the presence of coro-
lying cardiac rhythm is sinus (rate: 90 beats nary heart disease, should be suppressed aggres-
per minute), but frequent multifocal VPCs sively.
cause many episodes of ventricular group beats,
a precursor of ventricular tachycardia.

B .=

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:g 1t§ ~I ::: :

.i~ : ::::t:: I :::~

 Case 16 / Diagnosis 47

CASE 16 itor ECG was ordered to assess the nature of

his palpitations associated with exertional
This Holter monitor ECG was obtained from dyspnea.
a 79-year-old man who has been taking digoxin
(0.25 mg) and hydrochlorothiazide (50 mg) 1. What is the 12-lead ECG diagnosis?
daily for chronic congestive heart failure due 2. What is the Holter monitor ECG diagnosis?
3. What is the treatment of choice?
to hypertensive heart disease. The Holter mon-
48 Ambulatory Electrocardiography

Diagnosis tic approach should be a careful increase of the

12-1ead ECG: The underlying cardiac maintenance dosage of digitalis as the clinical
rhythm is atrial fibrillation (AF) with an ideal circumstances permit. Otherwise, oral propran-
ventricular rate (70 to 90 beats per minute) olol (lnderal) (10 to 30 mg, three to four
and occasional ventricular premature contrac- times daily) should be added. If these two
tions (VPCs). The diagnosis of left ventricular therapeutic approaches are ineffective, therapy
hypertrophy is obvious, on the basis of tall R is problematic, a common clinical experience.
waves in leads V4-6 and a deep S wave in lead Restoration of sinus rhythm is difficult with
V 1 associated with the typical secondary S-T, chronic AF in elderly individuals, either by
T wave changes in the left precordial leads. In quinidine or direct current (DC) shock, be-
addition, an old anterior myocardial infarction cause sinus node dysfunction, the sick sinus
is a remote possibility. syndrome, is most likely present in this age
group (see Table 9). Therefore, a DC shock is
Holter Monitor ECG: The rhythm strips not justified in elderly people with chronic AF.
A through D are not continuous. The under- The only hope is to use an artificial pacemaker
lying cardiac rhythm is AF throughout the in conjunction with digitalis and/or proprano-
tracing, but there is a marked acceleration of lol at a relatively larger dosage because drug-
ventricular rate (strips B and C) that corre- induced advanced A-V block that is causing
sponds to the exertional dyspnea during mini- an extremely slow ventricular rate can be con-
mal daily activity (from his diary). Note the trolled by artificial pacing. When the underlying
VPC on strip D. cardiac disorder is far advanced, the control
It is extremely difficult to maintain the ideal of the ventricular rate in chronic AF by drugs
ventricular rate in chronic AF with a mainte- alone (digitalis and/or propranolol) is a diffi-
nance digitalis dosage. Thus, the first therapeu- cult problem, especially in elderly individuals.

D
 Case 17 / Diagnosis 49

CASE 17 physical findings were entirely unremarkable,

except for an occasional cardiac irregularity on
A 71-year-old man with coronary artery dis- auscultation. There was no evidence of con-
ease was seen in his family physician's office gestive heart failure.
because he complained of palpitations. He had
1. What is the 12-lead BCG diagnosis?
suffered from myocardial infarction (MI) 4
2. What is the Holter monitor BCG diagnosis?
months earlier, but his recovery was unevent-
3. What is the treatment of choice?
ful. He was not taking any medication. His
50 Ambulatory Electrocardiography

Diagnosis is sinus (rate: 86 beats per minute), but there

12-lead ECG: The underlying cardiac are frequent atrial premature contractions caus-
rhythm is sinus (rate: 89 beats per minute), ing atrial bigeminy (strip A), which leads to
but there are occasional ventricular premature a paroxysmal atrial tachycardia (rate: 148
contractions (VPCs). The striking ECG ab- beats per minute) shown on strips Band C.
normality on this tracing is an old localized In ~ddition, there are frequent VPCs (strip
anterior MI evidenced by qrS waves in leads D).
V 2-3 with inverted T waves. In addition, marked Although there are several therapeutic ap-
left axis deviation of the QRS complexes (QRS proaches to choose from under these circum-
axis: -45 degrees) indicates a left anterior stances, oral quinidine (0.3 to 0.4 gm every
hemiblock. The above ECG findings are not 6 hr) is the drug of choice. Quinidine will
sufficient to explain his frequent episodes of effectively suppress atrial as well as ventricular
palpitations. Therefore, a Holter monitor ECG ectopic impulse formation. If there is any evi-
was requested. dence of heart failure, however, digitalis is the
drug of choice. When quinidine is ineffective
Holter Monitor ECG: Strips A through D for his arrhythmias, procainamide or proprano-
are not continuous. The basic cardiac rhythm lol should be tried.

o
 Case 18 / Diagnosis 51

CASE 18 per day); physical examination was negative

other than frequent extrasystoles and moderate
A 33-year-old, obese, apparently healthy obesity.
woman was examined at the Cardiac Clinic for
1. What is the cardiac rhythm diagnosis?
the evaluation of palpitations. The only perti-
2. What is the treatment of choice?
nent history was that she was found to be a
heavy smoker (two to three packs of cigarettes
52 Ambulatory Electrocardiography

Diagnosis the best therapeutic approach for any cardiac

12-lead ECG: The underlying cardiac arrhythmia is to eliminate the direct cause (e.g.,
rhythm is sinus (rate: 84 beats per minute), coffee, tea, tobacco), if possible (see Table 6).
but there are frequent ventricular premature If VPCs are not suppressed when the patient
contractions (VPCs). The rest of the BCG stops smoking, possible underlying disorders
findings are within normal limits, other than (e.g., mitral valve prolapse syndrome, hyper-
the low QRS voltage. thyroidism) should be carefully investigated.
Various anti-arrhythmic drugs (propranolol,
Holter Monitor ECG: Strips A through D quinidine, procainamide) may be effective in
are not continuous. The basic cardiac rhythm the treatment of persisting VPCs even after
is sinus tachycardia (rate: 105 to 140 beats the patient has stopped smoking.
per minute), which is very common in obese Needless to say, obesity and smoking are
individuals, but there are frequent VPCs pro- very serious risk factors for coronary artery
ducing two to three ventricular group beats. disease and hypertension. Weight control
The treatment of choice under this circum- should be a part of the medical treatment in
stance is to eliminate the probable direct cause conjunction with careful evaluation of possibly
-smoking (see Table 6). As described earlier, abnormal serum lipids.

D
 Case 19/ Diagnosis 53

CASE 19 examination and echocardiogram confirmed the

diagnosis of mitral valve prolapse syndrome
A 29-year-old female was referred to a cardiol- (MVPS).
ogist for the evaluation of abnormal heart
1. What is the 12-lead ECG diagnosis?
sound associated with palpitations. She was not
2. What is the Holter monitor EeG diagnosis?
taking any drugs, and she denied any unusual
3. What is the drug of choice?
personal habits (e.g., excessive use of coffee,
tea, or Coca-Cola; heavy smoking). Physical
54 Ambulatory Electrocardiography

Diagnosis The drug of choice for cardiac arrhythmias

12-1ead ECG: The cardiac rhythm is sinus associated with the MVPS is oral propranolol
(rate: 98 beats per minute) with frequent ven- (10 to 40 mg, three to four times daily). Oral
tricular premature contractions (VPCs) caus- propranolol (Inderal) therapy is also beneficial
ing an intermittent ventricular bigeminy. Note for anxiety or chest pain, which is a frequent
the inverted T waves in leads III and aVF; this component of the syndrome.
finding is probably the most common BCG It has been shown that VPCs and paroxys-
abnormality in the MVPS. This BCG finding mal atrial tachycardia are the most common
often resembles a recent diaphragmatic myo- cardiac arrhythmias in patients with MVPS.
cardial infarction. In addition, left ventricular Various degrees of A-V conduction disturb-
hypertrophy (LVH) is suspected merely by the ances may also occur in this syndrome, and in
voltage criteria, but high left ventricular voltage rare cases, permanent artificial pacemaker im-
is very common in healthy young individuals plantation may be required for complete A-V
and of no clinical significance. Under these block. Sudden death has been reported in
circumstances, the finding is simply "high left MVPS, and ventricular fibrillation triggered by
ventricular voltage" without any indication of frequent VPCs is considered to be the direct
LVH. cause of death in most cases. Propranolol is
Holter Monitor ECG: Rhythm strips A very effective for various cardiac arrhythmias
through D are not continuous. The underlying with or without associated chest pain in MVPS.
rhythm is sinus tachycardia (rate: 110 to 120
beats per minute) with frequent VPCs causing
ventricular group beats.

D
 Case 20/ Diagnosis 55

CASE 20 1. What is the 12-lead EeG diagnosis?

2. What was the fundamental cardiac rhythm
A 71-year-old man who received a permanent diagnosis before pacemaker implantation?
artificial pacemaker implantation 1.5 yr earlier 3. What type of artificial pacemaker was im-
visited a cardiologist's office for a routine planted?
checkup.
56 Ambulatory Electrocardiography

Diagnosis is an intermittent artificial pacemaker-induced

12-1ead ECG: The underlying cardiac ventricular rhythm (P) (rate: 70 beats per
rhythm is sinus (rate: 90 beats per minute), minute). The artificial pacemaker takes over
but there is an intermittent artificial pacemaker- the ventricular activity whenever an unexpected
induced ventricular rhythm (the first two ventricular pause is longer than the pre-set
beats). The striking ECG abnormality is the pacing escape interval. This mode of pacing is
evidence of an old extensive anterior myocar- a typical feature of the demand ventricular
dial infarction (MI), which is manifested by pacemaker.
loss of R waves or abnormal (pathologic) Q It is obvious that the P-R intervals are con-
waves in all the precordial leads, in addition stant throughout, but there are occasional
to leads I and aVL. The S-T segment in some blocked (non-conducted) sinus P waves (X).
leads is still elevated, which suggests a ventricu- This ECG finding is a characteristic feature of
lar aneurysm. The QRS complex is broad; this the Mobitz type II A-V block (see also Case
finding is termed "diffuse (nonspecific) intra- 6). Thus, the fundamental rhythm disorder be-
ventricular block" which is not due to right or fore implantation of the permanent pacemaker
left bundle branch block (RBBB or LBBB, was a Mobitz type II A-V block. Note one
respectively). Diffuse intraventricular block is ventricular fusion beat (FB).
often produced by an extensive MI. Another Mobitz type II A-V block is often produced
ECG abnormality is left atrial hypertrophy, by an anterior MI, and the block is irreversible.
which is manifested by deep and broad nega- It has been shown that the Mobitz type II A-V
tive P waves in leads V1-2. block represents an infra-nodal block, an in-
complete trifascicular block (a form of bilateral
Cardiac Rhythm Strips: Note the sinus P bundle branch block) (see Table 10). A per-
waves (arrows). The underlying cardiac rhythm manent artificial pacemaker is indicated for
is sinus (rate: 90 beats per minute), but there every patient with a Mobitz type II A-V block.
 Case 21 / Diagnosis 57

CASE 21 denied any unusual personal habits (e.g., ex-

cessive use of coffee or tea), and was not taking
An anxious, 61-year-old woman without de- any drugs. Her physical findings were entirely
monstrable heart disease was examined because unremarkable other than her "usual" anxiety.
she complained of frequent episodes of palpi-
1. What is the cardiac rhythm diagnosis?
tations. She stated that the episodic palpitations
2. What is the treatment of choice?
always seemed to be triggered by anxiety. She
58 Ambulatory Electrocardiography

Diagnosis anxiety-induced PAT, is propranolol (Inderal).

12-lead ECG: The cardiac rhythm is sinus The drug is usually effective in the oral dosage
with a rate of 87 beats per minute. The ECG of 10 to 40 mg, three to four times daily. In
tracing is entirely within normal limits. addition, mild tranquilizers or sedatives (e.g.,
Valium or Librium) may also be beneficial
Holter Monitor ECG: The strips A through under these circumstances.
D are not continuous. The underlying cardiac It is extremely important to remember that
rhythm is sinus (rate: 80 beats per minute), thyroid function should be determined in every
but paroxysmal atrial tachycardia (PAT) (rate: individual with unexplainable cardiac arrhyth-
160 beats per minute) occurs abruptly (strip mias to exclude a possible hyperthyroidism. It
A) and also terminates abruptly (strip D). can be said that hyperthyroidism is probably
Thus, her Holter monitor ECG tracing shows the most common noncardiac cause of parox-
a characteristic feature of PAT. ysmal atrial tachyarrhythmias, and, particularly,
It has been repeatedly demonstrated that of paroxysmal atrial fibrillation.
PAT is commonly triggered by an anxiety spell, All patients who experience paroxysmal
especially in females with or without demon- supraventricular tachycardias should be in-
strable heart disease. The drug of choice for all structed in the common methods (e.g., carotid
catecholamine-induced arrhythmias, including sinus stimulation) of terminating the paroxysm.

D
 Case 22 / Diagnosis 59

CASE 22 1. What is the cardiac rhythm diagnosis?

2. What is the treatment of choice?
This Holter monitor ECG was recorded from
a 30-year-old woman because of palpitations.
Her 12-lead EeG was within normal limits
(not shown here).

c
60 Ambulatory Electrocardiography

Diagnosis in strip C). In strip B, the P wave direction

The rhythm strips A through C are not con- changes from upright (arrows pointing up) to
tinuous. The cardiac rhythm is sinus arrhyth- inverted P waves (arrows pointing down).
mia, with a wandering atrial pacemaker to the This type of wandering atrial pacemaker is
A-V junction and one ventricular premature clinically insignificant, being considered an ex-
contraction (V). Strip A shows a purely sinus aggerated form of sinus arrhythmia. Accord-
rhythm, whereas strip C reveals a A-V junc- ingly, no treatment is indicated other than re-
tion escape rhythm, with a rate of 60 to 65 assurance.
beats per minute (Note the inverted P waves
 Case 23 / Diagnosis 61

CASE 23 (not shown here). She was not taking any

medication.
These Holter monitor ECG rhythm strips were 1. What is the cardiac rhythm diagnosis?
obtained from a 59-year-old woman complain- 2. What is the treatment of choice?
ing of episodic dizziness. Cardiac examination,
including a 12-lead ECG, was unremarkable

D
62 Ambulatory Electrocardiography

Diagnosis in the strip D, the ventricular rate becomes

The cardiac rhythm strips A through Dare extremely slow (36 to 38 beats per minute).
not continuous. Note the sinus P waves (ar- Consequently, insufficient cardiac output can
rows). The cardiac rhythm is sinus arrhythmia cause dizziness and even episodes of syncope.
with an intermittent 2: 1 Mobitz type II sino- As described earlier, S-A block is an ex-
atrial (S-A) block. Note that the long P-P pression of the sick sinus syndrome (see Table
interval is twice the basic P-P cycle (each num- 9). The treatment of choice is, of course, im-
ber is one-hundredth of a second). When a plantation of a demand ventricular pacemaker.
2: 1 S-A block occurs consecutively, as seen
 Case 24 / Diagnosis 63

CASE 24 drugs. His 12-lead ECG shows sinus arrhyth-

mia with a rate of 60 to 70 beats per minute
These Holter monitor ECG rhythm strips were and a nonspecific S-T, T wave change (not
obtained from a 72-year-old man with a history shown here).
of blackout spells. His blood pressure was
1. What is the cardiac rhythm diagnosis?
mildly elevated, but there was no evidence of
2. What is the treatment of choice?
congestive heart failure. He was not taking any

D
64 Ambulatory Electrocardiography

Diagnosis probably as a result of a long period of sinus

Rhythm strips A through D are not continuous. arrest. This BeG finding is a good example of
Note the sinus P waves (arrows). The cardiac the sick sinus syndrome (see Table 9). Note a
rhythm is marked sinus bradycardia (atrial ventricular premature contraction (V). A per-
rate: 42 to 45 beats per minute) with an inter- manent artificial pacemaker implantation is the
mittent A-V junctional escape rhythm (N) treatment of choice, since no drug is effective
(ventricular rate: 40 to 47 beats per "minute) in this condition.
 Case 25 / Diagnosis 65

CASE 25 with sinus arrhythmia (rate: 50 to 60 beats per

minute) and a nonspecific abnormality of the
A 59-year-old man presented with near- S-T segment and T wave (not shown here).
syncope episod((s. He was not taking any drugs
1. What is the cardiac rhythm diagnosis?
when the Holter monitor BCG was recorded.
2. What is the treatment of choice?
His 12-lead BCG showed sinus bradycardia

c
66 Ambulatory Electrocardiography

Diagnosis Under these circumstances, anti-arrhythmic

The rhythm strips A through C are not con- drug therapy is unsatisfactory. The treatment
tinuous. The cardiac rhythm is marked sinus of choice for the fiTS is the implantation of a
bradycardia (rate: 42 to 46 beats per minute) permanent artificial pacemaker. A slight, over-
with areas of sinus arrest and frequent ventricu- driving pacing rate (rate: 80 to 120 beats per
lar premature contractions (VPCs) (V). Thus, minute) may be needed to suppress the VPCs.
this BCG finding is a manifestation of the When the ventricular premature beats are not
brady-tachyarrhythmia syndrome (BTS), as a suppressed by artificial pacing, anti-arrhythmic
result of the advanced sick sinus syndrome (see drug therapy (quinidine or procainamide) may
Table 9). be required in addition to the artificial pacing.
 Case 26 / Diagnosis 67

CASE 26 limits otherwise (not shown here). She was not

taking any drugs when the Holter monitor BCG
These Holter monitor rhythm strips were re- was recorded.
corded from a 69-year-old woman with palpi- 1. What is the cardiac rhythm diagnosis?
tations associated with dizziness. Her 12-lead 2. What is the treatment of choice?
BCG showed occasional ventricular premature
contractions (VPCs), but was within normal

D
68 Ambulatory Electrocardiography

Diagnosis ventricular escape beat (X) appears following

The cardiac rhythm strips A through D are not a long post-ectopic pause. This ECG finding
continuous. The cardiac rhythm is marked most likely represents a diseased A-V node in
sinus bradycardia (rate: 43 to 55 beats per addition to the sinus node dysfunction, a com-
minute) with frequent VPCs (V) followed by mon occurrence.
ventricular escape beats (X). Note the sinus The treatment of choice in this case is a
beats (S). Therefore, this Holter monitor ECG permanent artificial pacemaker. If the VPCs
finding represents a brady-tachyarrhythmia syn- are not suppressed by the artificial pacemaker,
drome secondary to the sick sinus syndrome. one or more anti-arrhythmic drugs (e.g., quini-
In this ECG tracing, the expected A-V junc- dine, procainamide, etc.) may be required.
tional escape beats failed to appear. Instead, a
 Case 27 / Diagnosis 69

CASE 27 minute) with occasional ventricular premature

contractions (VPCs) and a nonspecific abnor-
This Holter monitor BCG was obtained from mality of the T waves (not shown here).
an 80-year-old woman with syncope episodes.
1. What is the cardiac rhythm diagnosis?
She was not taking any drugs when the Holter
2. What is the treatment of choice?
monitor BCG was recorded. Her 12-lead BCG
showed sinus bradycardia (rate: 55 beats per

E
70 Ambulatory Electrocardiography

Diagnosis The cardiac rhythm on this Holter monitor

The cardiac rhythm strips A through B are not BCG is a typical example of a brady-tachy-
continuous. Note the sinus P waves (arrows). arrhythmia syndrome due to a far-advanced
The cardiac rhythm is a very unstable and slow sick sinus syndrome. The treatment of choice
sinus bradycardia, with periods of sinus arrest, is, again, implantation of a permanent artificial
a paroxysmal atrial fibrillation, with advanced pacemaker. In addition, one or more anti-ar-
A-V block, and a paroxysmal atrial flutter. In rhythmic drugs may be needed when the tachy-
addition, there are many bizarre QRS com- arrhythmia component persists after pacing.
plexes; the majority of them are due to aberrant
ventricular conduction (see Case 5), but some
of them are VPCs.
 Case 28 / Diagnosis 71

CASE 28 recorded. Her 12-lead ECG revealed a sinus

bradycardia with sinus arrhythmia (rate: 48
These Holter monitor ECG rhythm strips were to 57 beats per minute) and occasional ven-
obtained from a 62-year-old woman with fre- tricular premature contractions (VPCs) with
quent episodes of dizziness. She had almost left ventricular hypertrophy (not shown here).
fainted on several occasions. She was found to
1. What is the cardiac rhythm diagnosis?
have mild hypertension, but she was not taking
2. What is the treatment of choice?
any drugs when the Holter monitor ECG was
72 Ambulatory Electrocardiography

Diagnosis oxysmal atrial fibrillation is recorded (strip

Strips A through D are not continuous. Note A), and there are occasional VPCs (V).
the sinus P waves (arrows) . The cardiac The cardiac rhythpl diagnosis is another
rhythm is a markedly unstable sinus mecha- good example of a brady-tachyarrhythmia syn-
nism, with periods of extreme sinus brady- drome secondary to a far-advanced sick sinus
cardia and sinus arrest, leading to occasional syndrome (see Table 9). The treatment of
A-V junctional escape beats (N) as well as choice is, of course, a permanent pacemaker.
ventricular escape beats (X). In addition, par-
 Case 29 / Diagnosis 73

CASE 29 tively slow ventricular rate of 55 to 65 beats

per minute and occasional ventricular prema-
A 73-year-old woman was referred to a cardiol- ture contractions (VPCs) (not shown here).
ogist because of palpitations and dizziness. She
1. What is the cardiac rhythm diagnosis?
was not taking any drugs when the Holter mon-
2. What is the treatment of choice?
itor ECG was ordered. The 12-lead ECG
showed an atrial fibrillation (AF) with a rela-

0 '
74 Ambulatory Electrocardiography

Diagnosis This ECG finding is another expression of

Strips A through D are not continuous. The a brady-tachyarrhythmia syndrome due to an
cardiac rhythm is AF with an advanced A-V advanced sick sinus syndrome (SSS). It should
block producing a slow ventricular rate (42 to be noted that chronic AF with advanced A-V
46 beats per minute) and frequent VPCs, with block is a coinmon manifestation of advanced
ventricular group beats. Note that the ventricu- SSS (see Table 9).
lar cycle is not regular, and therefore, the diag- A permanent artificial pacemaker was im-
nosis of complete A-V block cannot be made. planted, with excellent results in this patient.
Under this circumstance the term "advanced"
or "high-degree" A-V block is used to express
the slow but irregular ventricular cycle in AF.
 Case 30 / Diagnosis 75

CASE 30 (AF) (ventricular rate: 55 to 65 beats per

minute) with occasional ventricular premature
These Holter monitor ECG rhythm strips were contractions (VPCs) and left ventricular hy-
obtained from an 82-year-old man with syn- pertrophy (not shown here).
cope episodes. He was not taking any drugs
1. What is the cardiac rhythm diagnosis?
when the Holter monitor ECG was ordered.
2. What is the treatment of choice?
His 12-lead ECG disclosed atrial fibrillation

o
76 Ambulatory Electrocardiography

Diagnosis escape beats to appear is most likely a result

The rhythm strips A through D are not con- of the diseased A-V node, in addition to sinus
tinuous. The underlying rhythm is AF, but the node dysfunction. There are also frequent mul-
ventricular rate is slow (43 to 46 beats per tifocal VPCs (V), with ventricular group beats.
minute) because of an advanced A-V block. These fIolter monitor BCG findings repre-
In addition, there are two types of escape beats: sent another example of a brady-tachyarrhyth-
one set represents A-V junctional escape beats mia syndrome secondary to advanced sick sinus
(B) and the other originates from the ventricles syndrome. A permanent artificial pacemaker
(A) and represents ventricular escape beats. was implanted, with remarkable results.
The intermittent failure of the A-V junctional
 Case 31 / Diagnosis 77

CASE 31 u1ar rate (50 to 60 beats per minute) and inter-

mittent broad QRS complexes (not shown
The Holter monitor EeG was obtained from a here).
54-year-old man with dizzy spells. He was not
1. What is the cardiac rhythm diagnosis?
taking any drugs when the Holter monitor EeG
2. What is the treatment of choice?
was recorded. His 12-lead EeG revealed atrial
fibrillation (AF), with a relatively slow ventric-

D
78 Ambulatory Electrocardiography

Diagnosis producing a ventricular escape (slightly accel-

The rhythm strips A through D are not con- erated) rhythm. Although the ventricular rate
tinuous. The underlying rhythm is AF, but the is not seriously slow in this tracing, a perma-
ventricular rate is relatively slow (48 to 55 nent artificial pacemaker implantation is recom-
beats per minute) and the ventricular cycle is mended becaues the block is considered to be
relatively regular. In addition, the QRS com- in the infra-nodal region (infra-nodal block),
plexes are broad and bizarre in most areas; which is usually due to permanent damage to
narrow (normal) QRS complexes are only the Purkinje system. This ECG is also another
occasionally seen. example of advanced sick sinus syndrome. The
The cardiac rhythm diagnosis of this Holter treatment of choice is, as noted, a permanent
monitor ECG is AF, with advanced A-V block pacemaker.
 Case 32 / Diagnosis 79

CASE 32 1. What is the 12-lead ECG diagnosis?

2. What is the Holter monitor ECG diagnosis?
A 77-year-old man was referred to a cardiolo- 3. What is the treatment of choice?
gist for the evaluation of many syncope epi-
sodes. He was not taking any drugs.
80 Ambulatory Electrocardiography

Diagnosis sinus bradycardia, with a first-degree A-V

12-lead ECG: The 12-lead BeG reveals block. Frequent multifocal ventricular prema-
sinus bradycardia (rate: 48 beats per minute), ture contractions with intermittent ventricular
with a first-degree A-V block (the P-R inter- tachycardia are easily recognized. Needless to
val: 0.32 sec) and a left anterior hemiblock say, these BeG findings are typical example
(QRS axis: -50 degrees) with a nonspecific of a serious brady-tachyarrhythmia syndrome
abnormality of the T waves. Obviously, the due to an advanced sick sinus syndrome. Im-
above BeG finding does not explain his symp- plantation of a permanent artificial pacemaker
tom, syncope episodes. Therefore, the Holter is, of course, the treatment of choice. One or
monitor BeG was obtained. more (usually quinidine or procainamide) anti-
arrhythmic drugs may be needed if the tachy-
Holter Monitor ECG: The strips A through arrhythmia component persists after pacing.
B are not continuous. The basic rhythm is again

B_
Cial
D_
E
 Case 33/ Diagnosis 81

CASE 33 lead BeG showed a sinus rhythm with occa-

sional atrial premature contractions (APes)
This Holter monitor BeG was obtained from and a nonspecific S-T, T wave change and/or
a 60-year-old woman with palpitations. She a digitalis effect (not shown here).
had been taking digoxin (0.25 mg daily) for
1. What is the cardiac rhythm diagnosis?
several years for chronic congestive heart fail-
2. What is the treatment of choice?
ure due to hypertensive heart disease. Her 12-

D
82 Ambulatory Electrocardiography

Diagnosis partial refractory period and is more pro-

Rhythm strips A through D are not continuous. nounced during atrial bigeminy (X) as a result
Note the ectopic P waves (arrows). The car- of Ashman's phenomenon (see Case 5, Diag-
diac rhythm is sinus (rate: 73 beats per min- nosis).
ute), with frequent APCs (arrows) causing The APCs were thought to be due to digitalis
areas of atrial bigeminy. Note that all the APCs intoxication, since the ectopic beats subsided
are followed by bizarre QRS complexes be- upon discontinuation of digitalis. There is an
cause of aberrant ventricular conduction (AVC) S-T segment depression compatible with the
(X). Aberrant ventricular conduction is ob- digitalis effect. These APCs, with AVC, closely
served because the atrial premature impulses resemble ventricular premature contractions.
are conducted to the ventricles during their
 Case 34 / Diagnosis 83

CASE 34 His 12-lead EeG revealed sinus rhythm with

occasional atrial premature contractions (APes)
These Holter monitor EeG rhythm strips were and a nonspecific S-T, T wave change and/or
obtained from a 73-year-old man who com- a digitalis effect (not shown here).
plained of dizziness. He has been taking di-
1. What is the cardiac rhythm diagnosis?
goxin (0.25 mg) and hydrochlorothiazide (25
2. What is the treatment of choice?
mg) daily for chronic congestive heart failure.

c
84 Ambulatory Electrocardiography

Diagnosis cardia. This slow ventricular rate is responsible

Strips A through C are not continuous. Note for his dizzy spells.
the ectopic P waves (arrows). The cardiac Digitalis intoxication is suspected because
rhythm is sinus bradycardia (rate: 52 beats the drug often produces sinus bradycardia and
per minute) with frequent, non-conducted frequent blocked APCs. Fortunately, his car-
(blocked) APCs (arrows). When non-con- diac rhythm problem subsided 2 days following
ducted atrial bigeminy occurs, as seen in strip discontinuation of digitalis. The most impor-
C, an extremely slow ventricular rate (34 beats tant therapeutic approach to digitalis-induced
per minute) is produced. Blocked atrial bi- arrhythmias is, obviously, immediate discon-
geminy closely simulates marked sinus brady- tinuation of digitalis.
 Case 35 / Diagnosis 85

CASE 35 lapse syndrome (MVPS). She was not taking

any drugs when the Holter monitor ECG was
A 36-year-old woman was referred to a cardiol- recorded.
ogist for evaluation of her palpitations. Her 1. What is the cardiac rhythm diagnosis?
12-lead ECG was within normal limits, but an 2. What is the treatment of choice?
echocardiogram confirmed a mitral valve pro-

o
86 Ambulatory Electrocardiography

Diagnosis It is a well-known fact that various cardiac

The rhythm strips A through D are not con- arrhythmias, particularly atrial tachyarrhyth-
tinuous. The underlying cardiac rhythm is sinus mias and ventricular premature contractions,
tachycardia (rate: 130 beats per minute). are common in patients with MVPS. Under
There are frequent atrial premature contrac- these circumstances, the drug of choice is oral
tions causing atrial bigeminy (strip. B), which propranolol (lnderal), 10-40 mg, three to four
leads to paroxysmal atrial tachycardia (rate: times daily.
210 beats per minute, strips C and D).
 Case 36/ Diagnosis 87

CASE 36 stress. His 12-lead ECG was within normal

limits. He was not taking any drugs.
This Holter monitor ECG was taken on a 56-
1. What is the cardiac rhythm diagnosis?
year-old man with palpitations. This patient
2. What is the treatment of choice?
showed no evidence of organic heart disease,
but he was found to be under unusual mental

c
88 Ambulatory Electrocardiography

Diagnosis (AVC) of different degrees occurs during par-

The rhythm strips A through D are not con- oxysmal tachycardia. The reason for the AVC
tinuous. The underlying rhythm is sinus tachy- is, obviously, the very rapid heart rate.
cardia (rate: 120 beats per minute), but there Cardiac arrhythmias as a result of emotional
are episodes of paroxysmal supraventricular excitement or any other similar clinical circum-
tachycardia with a rate of 215 to 250 beats per stances are best treated with small doses of
minute. This rapid rhythm is probably atrial propranolol (Inderal) (10 to 30 mg, three
tachycardia, but atrial flutter with 1: 1 A-V times daily), although sedatives or mild tran-
conduction is a possibility. It is interesting to quilizers may be beneficial; the direct cause of
note that aberrant ventricular conduction the arrhythmia should also be eliminated.
 Case 37 / Diagnosis 89

CASE 37 ECG showed a sinus rhythm (rate: 100 beats

per minute) with a nonspecific T wave abnor-
Holter monitor ECG rhythm strips were ob- mality (not shown here).
tained from a 60-year-old man who has been
1. What is the cardiac rhythm diagnosis?
suffering from angina associated with palpita- 2. What is the treatment of choice?
tions for several weeks. He has been taking sub-
lingual nitroglycerin for angina. His 12-1ead

D
90 Ambulatory Electrocardiography

Diagnosis Another important EeG finding in this trac-

The strips A through D are not continuous. ing are the deeply inverted T waves that are
The underlying cardiac rhythm is sinus with a indicative of myocardial ischemia.
rate of 96 beats per minute. Paroxysmal atrial The patient was digitalized, and no further
fibrillation (PAP), with a very rapid ventricu- episodes of PAP were observed. In addition,
lar response (ventricular rate: 165 to 200 the frequency of the angina was reduced by
beats per minute), is easily recognized. Also, digitalization.
many QRS complexes are bizarre during the
paroxysmal rapid heart action because of aber-
rant ventricular conduction.
 Case 38 / Diagnosis 91

CASE 38 controlled ventricular rate of 60 to 80 beats

per minute and a nonspecific S-T, T wave
These Holter monitor ECG rhythm strips were change and/or a digitalis effect (not shown
obtained from a 50-year-old man because he here).
complained of palpitations during physical ex-
1. What is the cardiac rhythm diagnosis?
ercise in spite of maintenance digitalis therapy
2. What is the treatment of choice?
(digoxin, 0.25 mg daily). His 12-lead ECG
revealed atrial fibrillation (AF) with an ideally

D
92 Ambulatory Electrocardiography

Diagnosis was effective in preventing the exercise-induced

Strips A through D are not continuous. The rapid heart action in this patient. If it is not
cardiac rhythm is AF, but marked acceleration feasible to increase the digitalis dosage, or if
of the ventricular rate was observed during such an increase is ineffective, a small amount
physical exercise (strips B and C). A slight (10 to 30 mg, three to four times daily) or oral
increase in his daily digoxin (0.375 mg) dosage propranolol (lnderal) should be tried.
 Case 39 / Diagnosis 93

CASE 39 Atromid-S, he had been taking sublingual nitro-

glycerin (p.r.n.) for chest discomfort. His phys-
A 63-year-old, slightly obese male was referred ical findings were unremarkable except for a
by his family physician for the evaluation of carotid bruit on the left (the patient denies
his cardiac status, and particularly his cardiac any symptom compatible with carotid artery
rhythm problems. He had been relatively stenosis). His vital signs were also within nor-
asymptomatic except for occasional episodes mal limits (blood pressure, 140/90 mm Hg;
of tightness in the chest and irregular heart pulse, 72/min regular; respiration, 13/min).
beats. Although his electrocardiogram shows Although he had been experiencing an occa-
definite evidence of an old diaphragmatic (in- sional irregularity of heart beat, no cardiac
ferior) and posterior myocardial infarction arrhythmia was detected either by physical ex-
(MI) (not shown here), he was unable to re- amination or by a routine 12-lead electrocar-
call any episode suggestive of a heart attack. diogram (not shown here).
In addition to the evidence of old MI, his
1. What is the cardiac rhythm diagnosis during
several electrocardiograms showed an intermit-
Atromid-S therapy?
tent right bundle branch block. He had been
2. What is the treatment of choice?
placed on Atromid-S, because of high serum
cholesterol and slight obesity. In addition to

D
94 Ambulatory Electrocardiography

Diagnosis Atromid-S was discontinued immediately,

The rhythm strips A through D are not con- and the Holter monitor EeG was repeated
tinuous. The first tracing was taken during within 2 wk after its discontinuation. It showed
Atromid-S therapy, the second 2 weeks after a sinus rhythm with no cardiac arrhythmias.
discontinuation of the drug. The value of detecting transient and intermit-
To confirm the presence or absence and the tent cardiac arrhythmias by a Holter monitor
type of cardiac arrhythmia, the Holter monitor EeG is demonstrated in this case. It is well
EeG was taken. As expected, the Holter moni- known that Atromid-S may produce various
tor EeG during Atromid-S therapy showed a cardiac arrhythmias. Thus, elimination of the
sinus rhythm with frequent atrial (arrows) as etiologic factor, namely Atromid-S is, of
well 'as ventricular premature contractions (V) course, the treatment of choice.
and paroxysmal atrial tachycardia (see the first
tracing).

c
 Case 40 / Diagnosis 95

CASE 40 within normal limits, and no ectopic beats were

present (not shown here). The clinical diagno-
A 32-year-old female was referred to a cardiol- sis of mitral valve prolapse syndrome (MVPS)
ogist for evaluation of her cardiac status be- was confirmed by echocardiography. The Hol-
cause of atypical chest pain associated with ter monitor ECG was requested in order to
palpitations of 6 mos duration. On physical determine the nature of her palpitations.
examination, she was in no distress and the 1. What is the cardiac rhythm diagnosis?
only abnormal findings included an intermittent 2. What is the treatment of choice?
mid-systolic click and a late systolic murmur
at the apex. The 12-1ead ECG was entirely

c
96 Ambulatory Electrocardiography

Diagnosis mias, particularly ventricular premature beats,

The rhythm strips A through C are not con- are the most common finding in MVPS. Pro-
tinuous. The cardiac rhythm is sinus (rate: 76 pranolol (Inderal) 10 mg, 3 times daily, was
beats per minute), with frequent ventricular prescribed for this patient, with excellent re-
premature beats causing ventricular trigeminy. sults.
It is well known that various cardiac arrhyth-
 Case 41 / Diagnosis 97

CASE 41 His 12-lead EeG reveals sinus rhythm, evi-

dence of an old DMI, and left ventricular hy-
These Holter monitor EeG rhythm strips were pertrophy (not shown here). No arrhythmia is
obtained from a 39-year-old hypertensive man observed on the 12-lead EeG.
who had suffered a diaphragmatic (inferior) 1. What is the cardiac rhythm diagnosis?
myocardial infarction (DMI) 6 mos earlier. 2. What is the treatment of choice?
The Holter monitor EeG was ordered because
of palpitations. He was not taking any drugs.

o
98 Ambulatory Electrocardiography

Diagnosis ularly coronary heart disease and cardiomyop-

The rhythm strips A through D are not con- athy, and digitalis intoxication. Thus, multi-
tinuous. The Holter monitor BCG revealed focal VPCs are considered malignant, and they
sinus rhythm (rate: 85 beats per minute) and must be treated (see Table 8). The commonly
frequent multifocal ventricular premature con- used oral drugs include quinidine and procain-
tractions (VPCs) with areas of ventricular bi- amide (Pronestyl) when these arrhythmias are
geminy and ventricular group beats. Note that associated with coronary heart disease or other
there are three or four different forms of VPCs. forms of organic heart disease. Diphenylhydan-
It has been shown that multifocal VPCs are toin (Dilantin), however, is the drug of choice
usually found in organic heart disease, partic- for digitalis-induced ventricular arrhythmias.
 Case 42 / Diagnosis 99

CASE 42 rhythm with occasional ventricular premature

contractions (VPCs) and eyidence of an an-
Holter monitor rhythm strips were obtained terior myocardial infarction (not shown here).
from a 68-year-old man with a history of an-
1. What is the cardiac rhythm diagnosis?
terior myocardial infarction 1 yr earlier. The
2. What is the treatment of choice?
Holter monitor ECG was ordered because of
palpitations. His 12-lead ECG showed sinus

c
100 Ambulatory Electrocardiography

Diagnosis Unit for active treatment. Lidocaine (Xylo-

Strips A through C are not continuous. The caine) (75 mg) was injected intravenously,
Holter monitor ECG reveals sinus tachycardia followed by a continuous intravenous infusion
(rate: 118 beats per minute) and frequent mul- (2 mg/min), with excellent results. Oral pro-
tifocal VPCs leading to ventricular tachycardia phylactic therapy with quinidine (0.3 to 0.4
(VT) (rate: 150 to 165 beats per minute). gm every 6 hr) or procainamide (0.25 to 0.5
The patient was hospitalized immediately gm every 3 to 4 hr) is recommended after
and put in the Intermediate Coronary Care termination of VT.
 Case 43 / Diagnosis 101

CASE 43 1. What is the 12-lead ECG diagnosis?

2. What is the Holter monitor ECG diagnosis?
An 80-year-old man with a history of a pre- 3. What is the treatment of choice?
vious "heart attack" was admitted to the hos-
pital because of a near-syncope attack.
102 Ambulatory Electrocardiography

Diagnosis Holter Monitor ECG: The rhythm strips

12-lead ECG: The cardiac rhythm is sinus A through D are not continuous. The Holter
with a rate of 73 beats per minute. The striking monitor BeG reveals sinus rhythm (arrows)
BeG abnormalities include a bifascicular block, with a Mobitz type II A-V block and an inter-
consisting of a right bundle branch block mittent 2: 1 A-V block. Note the sinus P waves
(RBBB) and a left anterior hemiblock (LAHB) (arrows). A Mobitz type II A-V block is con-
(QRS axis: -50 degrees), and an old antero- sidered to be a precursor of a complete A-V
septal myocardial infarction associated with block as a result of a complete trifascicular
left ventricular hypertrophy. These BeG find- block (see Table 10).
ings are not sufficient to explain his symptom A permanent artificial pacemaker (demand
-near-syncope. Therefore, the Holter monitor unit) implantation is the treatment of choice.
BeG was ordered.

c
D
 Case 44 / Diagnosis 103

CASE 44 mia was detected (not shown here). She was

not taking any drugs.
This Holter monitor ECG was recorded from
1. What is the cardiac rhythm diagnosis?
a 77-year-old woman who complained of dizzi-
2. What is the treatment of choice?
ness. Her 12-lead ECG shows sinus rhythm
with a first degree A-V block; no other arrhyth-

o
104 Ambulatory Electrocardiography

Diagnosis beats per minute) is produced because of the

The rhythm strips A through D are not con- relatively slow basic sinus rate; this is respon-
tinuous. Note the sinus P waves (arrows). The sible for the patient's dizzy spells.
cardiac rhythm is sinus (arrows) with a Wencke- A permanent artificial pacemaker (demand
bach (Mobitz type I) A-V block and an inter- unit) was implanted, with excellent results.
mittent 2: 1 A-V block. When a 2: 1 A-V block The Mobitz type I A-V block has been de-
occurs, an extremely slow ventricuiar rate (32 scribed in detail elsewhere (see Case 6).
 Case 45 / Diagnosis 105

CASE 45 physical examination revealed no significant

change. The office 12-lead BeG showed a slight
A 72-year-old man being followed with the sinus bradycardia and a left ventricular hyper-
diagnosis of hypertensive heart disease has trophy (not shown here).
been in normal sinus rhythm and has been
1. What is the cardiac rhythm diagnosis?
taking digoxin for several years for chronic
2. What is the most likely underlying cause of
congestive heart failure. Prior to this Holter
his arrhythmia?
monitor recording, the patient began to have
3. What is the treatment of choice?
episodes of increasing shortness of breath, but

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106 Ambulatory Electrocardiography

Diagnosis a complete A-V dissociation. Note the sinus P

The rhythm strips A through D are not con- waves (arrows). It is well known that a high-
tinuous. The Holter monitor recording demon- degree or complete A-V block is common in
strates a sinus rhythm with an A-V junctional digitalis intoxication, especially in elderly in-
escape rhythm (rate: 56 beats per minute) as dividuals. There was improvement with with-
the result of a complete A-V block producing drawal of the drug within a week.
 Case 46 / Diagnosis 107

CASE 46 generator with a well-healed surgical scar on

the right upper chest wall. She denied any car-
These Holter monitor EeG rhythm strips were diac symptoms and was not taking any drugs.
obtained from a 59-year-old woman following
1. What is the cardiac rhythm diagnosis?
implantation of a permanent demand pace-
2. What is the mode of pacing?
maker, in order to assess the function of the
3. What underlying cardiac rhythm disorder
artificial pacemaker. Her physical findings were
required the permanent pacing?
entirely unremarkable except for the pulse

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108 Ambulatory Electrocardiography

Diagnosis over the ventricular activity whenever the

The rhythm strips A through D are not con- expected sinus beats failed to appear as a result
tinuous. The underlying cardiac rhythm is sinus of sinus arrest-sick sinus syndrome. Note the
rhythm (rate: 90 to 100 beats per minute), but frequent ventricular fusion beats (FB).
there are periods of demand pacemaker-induced The sick sinus syndrome is the underlying
ventricular rhythm (rate: 73 beats per minute). cardiac rhythm disorder, which requires per-
As can be seen, a demand pacemaker takes manent pacemaker implantation (see Table 9).
 Case 47 / Diagnosis 109

CASE 47 maker and to document the slow pulse rate

episodes. He was not taking any drugs.
A 68-year-old man with a ventricular demand
1. What is the cardiac rhythm diagnosis?
pacemaker in place for 20 month~ had n?ted
2. What is the cause of the slow pulse rate?
a slowing of his pulse rate from tlme to tlme.
3. What is the treatment of choice?
The Holter monitor EeG recording was per-
formed to evaluate the function of the pace-

c
110 Ambulatory Electrocardiography

Diagnosis position. Repositioning the electrode restored

The rhythm strips A through C are not con- the consecutive ventricular capture by the arti-
tinuous. The artificial pacemaker intermittently ficial pacemaker. Other forms of malfunction-
fails to capture the ventricles (X). The pa- ing artificial pacemaker are excluded.
tient's underlying rhythm is most likely atrial Note that there are frequent natural beats
fibrillation (AF). The pacemaker electrode in (0), and the underlying cardiac rhythm is AF
this patient had shifted and was in the wrong with advanced A-V block.
 Case 48 / Diagnosis 111

CASE 48 sinus rhythm and was within normal limits (not

shown here) .
These Holter monitor BeG rhythm strips were
1. What is the BeG diagnosis?
obtained from a 21-year-old man who has been
2. What is the fundamental mechanism under-
suffering from frequent episodes of palpitations.
lying this BeG abnormality?
The cardiac examination was entirely unre-
3. What is the treatment of choice?
markable. The patient's 12-lead BeG showed

c
112 Ambulatory Electrocardiography

Diagnosis The fundamental mechanism underlying this

The rhythm strips A through C are continuous. unique ECG finding in the WPW syndrome is
The cardiac rhythm in the Holter monitor ECG diagrammatically illustrated. The uninterrupted
is sinus arrhythmia with an intermittent Wolff- line indicates the anomalous conduction in the
Parkinson-White (WPW) syndrome (X, strip WPW syndrome; the dotted line, normal con-
A). The first one-half of strip A reveals a nor- duction. The P-R and P-R' intervals are A-V
mal A-V conduction, whereas the remaining conduction times in the WPW syndrome and
strips show an anomalous A-V conduction due normal conduction, respectively. The P-R in-
to the WPW syndrome. terval is shorter than the P-R' interval as a
The initial slurring of the QRS complex is result of a delta wave. Note that the P-Z and
often called a "delta wave," and is considered P-S intervals are constant during anomalous
to be the result of a premature activation of a and normal conduction. The T wave in the
portion of the ventricles as a result of an anom- WPW syndrome is inverted because of a sec-
alous A-V conduction via an accessory path- ondary T wave change.
way. The most important clinical significance of
The diagnostic criteria of the WPW syn- the WPW syndrome is the extremely high in-
drome are summarized as follows: cidence (50 to 75%) of various supraventricu-
lar tachyarrhythmias. This patient was found
1. Initial slurring (delta wave) of the QRS
to have frequent episodes of reciprocating tach-
complex
ycardia that required propranolol (lnderal)
2. Short P-R interval
therapy.
3. Prolonged QRS interval
Although a precise classification of the
4. Secondary T wave change (not always pres-
WPW syndrome is not possible in every case,
ent)
the syndrome has been classified into two
Among these diagnostic criteria, the most groups, A and B, depending on the direction
important finding is the initial slurring (delta of the delta wave.
wave) of the QRS complex, which is respon-
sible for a short P-R interval and a broad QRS
complex.
 Case 48 / Diagnosis 113

Delta-Wave

P
I
,
I

I I I
I I
I al'
I 1"
I I"
I I 11
14- P-R ----' :Q
I I I T
~P-R'~
I I I
~ p-z I ... I
I I I I I
,. : p-s -+--'~"I

DIAGRAM WOLFF-PARKINSON-WHITE SYNDROME

 Case 49 / Diagnosis 115

CASE 49 the nature of the paroxysmal rapid heart ac-

tions. His 12-lead BeG was entirely within
A 24-year-old, apparently healthy man was re- normal limits (not shown here).
ferred to a cardiologist for the evaluation of 1. What is the BeG diagnosis?
frequent rapid heart actions. The Holter moni- 2. How would you treat this patient?
tor BeG was obtained in order to determine

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116 Ambulatory Electrocardiography

Diagnosis When documentation of the nature of the

The rhythm strips A through D are not con- paroxysmal tachyarrhythmia is not possible on
tinuous. The Holter monitor ECG reveals sinus repeated Holter monitor recordings, small
arrhythmia with periods of marked sinus brady- amounts of oral propranolol (lnderal) (10 to
cardia (rate: 42 to 57 beats per minute). Un- 30 mg, three to four times daily) should be
fortunately, no episode of the paroxysmal rapid tried since in reciprocating tachycardia with a
heart action was recorded on the Holter moni- normal QRS complex, the most common tachy-
tor ECG. The most interesting finding, how- arrhythmia in the WPW syndrome, this drug
ever, was the Wolff-Parkinson-White (WPW) is the drug of choice.
syndrome, with multiple anomalous A-V con- The fundamental mechanism responsible for
ductions causing various QRS complex con- the ECG abnormality in the WPW syndrome
figurations. has been described (Case 48). The diagrams
Later, a paroxysmal supraventricular (re- explaining the mechanisms responsible for the
ciprocating) tachycardia was documented by tachyarrhythmias in the WPW syndrome are
repeating the Holter monitor ECG (not shown found elsewhere (see Case 50).
here) on this patient.
 Case 50 / Diagnosis 117

CASE 50 been documented. Thus, a Holter monitor ECG

was ordered.
A 47-year-old woman was referred to the Car-
1. What is the cardiac rhythm diagnosis?
diac Clinic for evaluation of her frequent pal-
2. What is the fundamental mechanism under-
pitations. Although her 12-lead ECG demon-
lying the various tachyarrhythmias in the
strated a type A Wolff-Parkinson-White
WPW syndrome?
(WPW) syndrome on several occasions (not
3. What is the drug of choice?
shown here), her tachyarrhythmias had never

A
-
118 Ambulatory Electrocardiography

Diagnosis The atrial premature impulse is then conducted

Strips A and B are not continuous. The Holter to both ventricles via the bundle branch system
monitor recording demonstrates three group (A). In B, the atrial impulse is conducted to
beats with "normal" QRS morphology (X) the atria, in retrograde fashion, to produce an
during sinus rhythm with anomalous (WPW inverted P wave. In C, the impulse is conducted
syndrome) A-V conduction. The implication clockwise to produce a reciprocating (reentry)
was that group beats with a normal QRS mor- cycle; the same cycle may repeat indefinitely.
phology represent reentry beats that conduct, Note that the QRS complex during tachycardia
in retrograde fashion, through the bypass tract is normal. Key: S, sinus node; d, delta wave;
and, in antegrade fashion, through the A-V P, inverted P wave.
junction. The P waves, however, are not clearly Diagram (Part II) illustrating a reciprocat-
seen in group beats. In this patient, recurrent ing tachycardia with anomalous conduction in
reciprocating tachycardias were treated with the WPW syndrome. The reentry cycle is
propranolol (lnderal). It has been shown that counter-clockwise, which is exactly the reverse
propranolol is the drug of choice in the treat- of that shown in the Part I diagram.
ment as well as the prevention of reciprocating It has been shown that a reciprocating tach-
tachycardia with normal QRS complexes in ycardia is the most common tachyarrhythmia
the WPW syndrome. associated with the WPW syndrome, and the
The fundamental mechanism underlying re- majority of cases show normal QRS complexes.
ciprocating tachycardia in the WPW syndrome Less commonly, atrial fibrillation (AF) may
is described as follows: be observed and atrial flutter (AFI), is ex-
Diagram (Part I) illustrating the mechanism tremely rare in the WPW syndrome. In both
of a reciprocating tachycardia with a normal AF and AFI, the QRS complexes are almost
QRS complex in the WPW syndrome. In A, always bizarre because anomalous A-V con-
the atrial premature impulse (A) is conducted duction and/or aberrant ventricular conduction
to the A-V node (N), but the atrial premature occur as the result of the extremely rapid
impulse is blocked in the anomalous pathway. ventricular rate.
 Case 50 / Diagnosis 119

I \
,,
,
\
\
\
\ \
\ \

, ' ..
\ \ I
\ ;

MECHANISM: RECIPROCATING TACHYCARDIA IN W P W SYNDROME

PART I: NORMAL QRS COMPLEX

A B

/-~
: eN
"\
\
~)-
.' \
,I
:
I

\
, \ '
\'
, ....
, \ I
, \
....... I
.. ......... _-

MECHANISM: RECIPROCATING T~CHYCARDIA IN W P W SYNDROME

PART II: ABNORMAL QRS COMPLEX (ANOMALOUS A-V CONDUCTION)

 Case 51 / Diagnosis 121

CASE 51 12-lead ECG revealed left ventricular hyper-

trophy but was otherwise unremarkable (not
This Holter monitor ECG was obtained from shown here).
a 60-year-old man who presented with dizzi-
ness. He was not taking any drugs, although 1. What is the ECG diagnosis?
he was found to be mildly hypertensive. The 2. What is the treatment of choice?

c I
• III

D ..
II I I
122 Ambulatory Electrocardiography

Diagnosis No treatment is required for an isolated

Rhythm strips A through D are not continuous. EeG finding, such as hemiblock. No direct
The Holter monitor rhythm strips show sinus cause for the patient's dizziness was found by
rhythm with a rate of 75 beats per minute. It this Holter monitor EeG. The repeated Holter
is interesting to note that the configuration of monitor EeG is scheduled.
the QRS complexes changes from time to time
as a result of an intermittent left anterior hemi-
block (X).
 Case 52 / Diagnosis 123

CASE 52 revealed a sinus rhythm and a nonspecific ab-

normality of the S-T, T wave changes (not
A Holter monitor BeG was obtained from a shown here).
56-year-old woman with exertional chest pain
1. What is the BeG diagnosis?
associated with lightheadedness. She was hy-
2. What is the treatment of choice?
pertensive and had been taking hydrochloro-
thiazide (50 mg daily). Her 12-lead BeG

D
124 Ambulatory Electrocardiography

Diagnosis however, was not related to the heart rate, since

The rhythm strips A through D are not con- it was rate-independent.
tinuous. The cardiac rhythm is sinus arrhyth- Non-paroxysmal ventricular tachycardia (ac-
mia with areas of sinus tachycardia (rate: 103 celerated ventricular rhythm) is closely simu-
to 110 beats per minute). It is noteworthy that lated during LBBB. The LBBB in this patient
there are two types of QRS complexes due is, of course, an incidental finding and unre-
to an intermittent left bundle branch block lated to her symptoms. Needless to say, no
(LBBB). Intermittent LBBB in this patient, treatment is indicated.
 Case 53 / Diagnosis 125

CASE 53 a sinus rhythm with a nonspecific abnormality

of the T waves (not shown here) .
A 74-year-old woman was seen by a physician
1. What is the cardiac rhythm diagnosis?
for evaluation of palpitations. She was not tak-
2. What is the treatment of choice?
ing any drugs. The cardiac examination was
unremarkable and her 12-lead EeG showed

o
126 Ambulatory Electrocardiography

Diagnosis Parasystole is most commonly found in

The rhythm strips A through D are not con- elderly individuals, but its presence is usually
tinuous. The basic cardiac rhythm shown in the clinically insignificant. It should be treated,
Holter monitor EeG is sinus, but there are however, if the patient suffers from significant
frequent ectopic retrograde P waves (arrows). symptoms (e.g., palpitations). Quinidine (0.3
On superficial examination, these ectopic P gm, four times daily) may be sufficient to sup-
waves appeared to be the result of frequent press parasystole. Unfortunately, parasystole
atrial or A-V junctional premature contrac- tends to be resistant to the commonly used
tions. But the correct diagnosis of this arrhyth- anti-arrhythmic drugs.
mia is A-V junctional parasystole, on the basis
of varying coupling intervals with constant,
shortest interectopic intervals.
 Case 54/ Diagnosis 127

CASE 54 during therapy, nor had any arrhythmia been

detected. On a follow-up visit to his physician,
This Holter monitor BCG is from a 75-year- occasional ectopic beats were noted on a rou-
old man with congestive heart failure. The pa- tine BCG (not shown here).
tient's symptoms and physical signs were well
1. What is the cardiac rhythm diagnosis?
controlled by daily digoxin (0.25 mg) and hy-
2. What is the treatment of choice?
drochlorothiazide (50 mg) every other day.
The patient had not complained of palpitations

D
128 Ambulatory Electrocardiography

Diagnosis Although ventricular parasystole is fre-

Strips A through D are not continuous. The quently observed in elderly individuals and in-
patient's Holter monitor recording reveals a dividuals with diseased hearts, the arrhythmia
ventricular parasystole in the presence of sinus is usually relatively benign and self limiting.
rhythm. Consideration had been given to the Thus, active treatment for parasystole is not
possibility of digitalis intoxication because of indicated unless the patient is significantly
the ventricular ectopic beats. But confirmation symptomatic (e.g., palpitations). When sup-
of the ventricular para systole by a Holter pression of the parasystolic rhythm is indicated,
monitor recording (each number is one- quinidine or procainamide should be tried.
hundredth of a second) excludes this possibil-
ity. It has been shown that parasystole is not
a digitalis-induced arrhythmia.
 Case 55/ Diagnosis 129

CASE 55 exercise electrocardiogram was positive, being

stopped because of chest pain at the stage 4
A 58-year-old man with a past history of dia- exercise level (not shown here). A Holter
phragmatic (inferior) myocardial infarction monitor BCG recording was obtained to docu-
had had nocturnal dyspnea for several weeks. ment the ischemic event during the patient's
The dyspnea was associated with a sensation usual activity including sleep.
of extreme heaviness in his chest. There was,
1. What is the BCG diagnosis?
however, no history of palpitation, chest pain,
2. What is the treatment of choice?
nausea, diaphoresis, or weakness. There was
no evidence of congestive heart failure. An

c
130 Ambulatory Electrocardiography

Diagnosis resented nocturnal left ventricular ischemia

The rhythm strips A through C are not con- probably produced by the increased venous
tinuous. As can be seen in the Holter monitor return associated with the supine position. The
ECG recording, during the night, with the pa- patient was given digoxin (0.25 mg daily) and
tient in bed, his S-T segment became markedly by the sixth day of therapy his nocturnal symp-
depressed; this finding represents subendocar- toms has disappeared. Later Holter monitor
dial injury. The patient awoke with a sensation ECG recordings showed no S-T segment de-
of heaviness in the chest and shortness of pression through the night, and the patient's
breath. It was assumed that the findings rep- symptoms have subsided.
 Case 56 / Diagnosis 131

CASE 56 BeG test was requested on this patient to assess

his functional capacity. Another use of the
A treadmill exercise (stress) BeG test was exercise testing, obviously, is the diagnostic
performed on a 68-year-old man with chronic purpose for coronary heart disease, but this
atrial fibrillation (AF) because he complained was not the primary consideration.
of marked dyspnea on exertion, which was as-
1. What is the result of the exercise BeG test?
sociated with palpitations. He had been taking
2. What is the best therapeutic approach?
digoxin (0.25 mg) and hydrochlorothiazide
(50 mg) daily for several years. The exercise
132 Ambulatory Electrocardiography

Diagnosis The result of the exercise ECG test clearly

12-lead ECG: The underlying cardiac demonstrates an extremely poor exercise toler-
rhythm is AF with a well-controlled ventricular ance. Thus, the first therapeutic approach will
rate (70 to 95 beats per minute). The ECG be a slight increase in the digitalis dosage as
abnormalities include a probable left ventricu- permitted by the clinical setting. When this
lar hypertrophy (LVH) and a digitalis effect. approach is difficult or ineffective, however,
, small doses (10 to 30 mg, three to four times
Exercise ECG Test: Each strip consists of daily) of oral propranolol (Inderal) should be
modified leads V 5 (upper strip) and II (lower tried. When both therapeutic approaches fail,
strip) in this tracing as well as the remaining far-advanced heart disease is usually present.
exercise ECG tracings when a 2-channel re- Direct current shock is not usually feasible
corder was utilized. Strips A and B were taken for chronic AF, such as that seen in here.
at rest in the supine and standing position, re- Therefore, a ventricular rate that is dispropor-
spectively. Strips C were taken during exercise, tionally increased by minimal exercise may be
whereas strips D are post-exercise tracings. The better controlled by digitalis (with or without
ventricular rate is markedly accelerated (160 propranolol) after artificial pacing when the
to 180 beats per minute) with minimal exercise drug alone is ineffective in controlling the ven-
(strips C), and the patient developed frequent tricular rate. In addition, frequent VPCs may
multifocal ventricular premature contractions be suppressed by artificial pacing, but quinidine
(VPCs) during the post-exercise period (strips or procainamide should be added if the VPCs
D). There is a significant S-T segment depres- persist. It has been shown that the production
sion during and after exercise, but the finding of frequent VPCs by a minimal exercise work-
cannot be interpreted as positive because digi- load (with less than 70% predicted maximal
talis as well as LVH frequently produce false heart rate) is a strong evidence to support
positive exercise ECGs. significant coronary artery disease.

o
 Case 57 / Diagnosis 133

CASE 57 heart rate associated with hypotension, but he

denied chest pain. He was able to perform up
A 57-year-old man with known coronary artery to stage 4 of the Chung'S exercise protocol.
disease was referred to our exercise laboratory The exercise was stopped prematurely because
for assessment of his functional capacity. He of marked fatigue.
has been taking sublingual nitroglycerin (p.r.n.) 1. What is the result of the exercise ECG test?
for his angina since his heart attack 6 mos
2. What is its clinical significance?
earlier.
He had developed marked slowing of the
134 Ambulatory Electrocardiography

Diagnosis horizontal to downsloping S-T segment depres-

12-1ead ECG: The cardiac rhythm is sinus sion with biphasic to inverted T waves during
(rate: 65 beats per minute), with occasional and after exercise associated with frequent ven-
atrial premature contractions. There is evi- tricular premature contractions and a period
dence of an old diaphragmatic lateral myocar- of A-V junctional escape rhythm. It has been
dial infarction. In addition, left ventricular hy- demonstrated that the development of hypo-
pertrophy is suggested. tension by exercise associated with marked
slowing of the heart rate is usually clinically
Exercise ECG Test: Strips A are recorded serious; here it indicates far-advanced multi-
at rest. Strips B and C were obtained during vessel coronary artery disease. Some investiga-
exercise, whereas strips D and E are post- tors consider the exercise-induced hypotension
exercise ECG tracings. a more specific sign than the S-T segment alter-
The exercise ECG test is interpreted as un- ation in the diagnosis of advanced coronary
equivocally positive, on the basis of significant artery disease.
 Case 58/ Diagnosis 135

CASE 58 other day. She was unable to perform the exer-

cise beyond stage 2 of the Chung's protocol
The exercise (treadmill) BCG test was ordered because of generalized fatigue and dyspnea.
for a 70-year-old mildly hypertensive woman
to assess her functional capacity. She has been 1. What is the exercise BeG diagnosis?
taking hydrochlorothiazide (50 mg) every 2. What is its clinical significance?
136 Ambulatory Electrocardiography

Diagnosis The development of left bundle branch

12-1ead ECG: The cardiac rhythm is sinus block (LBBB) during exercise is readily rec-
with a rate of 73 beats per minute. The diagno- ognized as the heart rate accelerates. Note a
sis of left ventricular hypertrophy (LVH) is normal QRS complex at rest (strip A). This
obvious, on the basis of tall R waves in leads finding is a form of rate-dependent LBBB,
V5-6 and deep S wave in lead V1 associated which has no clinical significance. The under-
with the secondary S-T, T wave change in the lying abnormality is often LVH in individuals
left precordial leads. with a fixed or rate-dependent LBBB.
Although the development of LBBB during
Exercise ECG Test: Strips A are resting exercise per se has no diagnostic or clinical
tracings. Strips B through E were taken during significance, the patient definitely shows a
exercise; strips Fare post-exercise tracings. marked impairment of functional capacity.
The maximal heart rate obtained was only 125
beats per minute.

I
B
D F
 Case 59/ Diagnosis 137

CASE 59 was requested because of atypical chest pain.

She was able to perform the exercise up to
A 70-year-old woman with a known heart con- stage 3 of the exercise protocol. The exercise
dition was referred to a cardiologist for evalua- test was stopped prematurely because of
tion of cardiac status. She was not taking any frequent ventricular premature contractions
drugs. Her physical findings were definitely ab- (VPCs) associated with chest pain.
normal; thus, right precordial leads (leads
1. What is the 12-lead ECG diagnosis?
VlR-6R) were obtained in addition to a conven-
2. What is the exercise ECG diagnosis?
tional 12-lead ECG. The exercise ECG test
138 Ambulatory Electrocardiography

Diagnosis exercise; strips F are post-exercise tracings. The

12-1ead ECG: At a glance, the limb leads exercise ECG test result is definitely positive
appear to show the tracing with reversed elec- on the basis of a significant horizontal S-T
trodes (with right and left arm leads reversed) segment depression with frequent VPCs asso-
because all the complexes in lead I are nega- ciated with chest pain. Note the frequent ven-
tive. On careful examination of the right pre- tricular group beats (three consecutive VPCs
cordial leads (V lR-6R), however, the diagnosis -strips D and E). The maximal heart rate was
of dextrocardia becomes obvious. Other than 145 beats per minute.
dextrocardia, there is no coexisting congenital It should be noted that the patient's dextro-
anomaly; the 12-lead ECG was within normal cardia had nothing to do with the development
limits, except as noted. of coronary artery disease.

Exercise ECG Test: Strips A are resting

tracings. Strips B through E were taken during

A c

B
D
 Case 60 / Diagnosis 139

CASE 60 He was unable to perform the exercise test

beyond stage 2 because of marked fatigue. Im-
A 67-year-old man was referred to the exer- mediately following the termination of exer-
cise laboratory for evaluation of cardiac status. cise, he developed a marked slowing of the
His physical examination failed to demonstrate heart rate associated with dizziness and slight
any abnormality, and his 12-lead ECG was hypotension. The maximal heart rate was only
within normal limits (not shown here). During 120 beats per minute.
a careful history taking, he admitted having
occasional dizziness and near-syncope episodes. 1. What is the cardiac rhythm diagnosis?
He was not taking any drugs. 2. What is the result of the exercise ECG test?

o
140 Ambulatory Electrocardiography

Diagnosis and this finding indicates a wandering pace-

Strips A are resting tracings, whereas strips B maker from the sinus node to the A-V junction
were recorded during exercise. The remaining (strips D through F). Note the occasional atrial
strips, C through G, are post-exercise ECG fusion beats (F).
tracings. The exercise ECG test result is, obviously,
It is obvious that there is a marked slowing positive. The sick sinus syndrome must be con-
of the heart rate during the immediate post- sidered when the sinus rate is not significantly
exercise period (strips C through F) associated increased by exercise and when the marked
with a significant horizontal to downsloping slowing of sinus rate persists with or without
S-T segment depression. The P wave configura- intermittent A-V junctional escape rhythm fol-
tion changes from upright (arrows pointing up) lowing termination of exercise.
to inverted (arrows pointing down) P waves,

G
 Case 61 / Diagnosis 141

CASE 61 maximal heart rate was 175 beats per minute

(not shown here). A portion of her exercise
A 33-year-old woman was referred to a car- BeG tracing is shown here. She was not taking
diologist for evaluation of atypical chest pain. any drugs.
Her physical finding was entirely unremarkable
and her 12-lead BeG was within normal limits 1. What is the exercise BeG diagnosis?
(not shown here). 2. What is its clinical significance?
She was able to complete a full, 7-stage exer- 3. What is the treatment of choice?
cise protocol without any problems, and her

A B

D
142 Ambulatory Electrocardiography

Diagnosis block. The patient, however, never developed

Strips A and B were taken at rest in the supine a higher-degree A-V block during or after ex-
and standing position, respectively. Strips C ercise. Exercise-induced first-degree block and
and D are post-exercise ECG tracings 1 min Wenckebach A-V block have been reported
apart. in apparently healthy individuals. This finding,
The striking ECG change induced by exer- therefore, is probably not clinically significant.
cise is a progressive lengthening of the P-R The exercise ECG test is interpreted as nega-
intervals causing a marked first degree A-V tive, and of course, no treatment is indicated.
 Case 62 / Diagnosis 143

CASE 62 He was able to complete the 6-stage exercise

protocol without any symptoms or BCG abnor-
A 64-year-old man was examined at the Car- mality, but ventricular premature contractions
diac Clinic for evaluation of palpitations that (VPCs) began to appear soon after the termi-
occurred during physical exercise. His physical nation of exercise (during the early recovery
finding was unremarkable, and his 12-lead period). His maximal heart rate was 155 beats
BCG was within normal limits (not shown per minute.
here). He denied chest pain and was not taking
1. What is the exercise BCG diagnosis?
any drugs. The exercise BCG test was requested
2. What is its clinical significance?
to assess the possible relationship between his
3. What is the treatment of choice?
palpitations and physical exercise. His 24-hr
Holter monitor BCG was reported to be nega-
tive (not shown here).

c
144 Ambulatory Electrocardiography

Diagnosis during the recovery period following exercise

Bach rhythm strip represents a modified lead is considered not to be diagnostic for organic
V 5. Strip A is a resting tracing, whereas strips heart disease, and particularly not coronary
B and C are continuous post-exercise BCG artery disease.
tracings. The frequent VPCs (V) producing Isolated exercise-induced VPCs may not re-
ventricular quadrigeminy in strips Band C quire treatment unless the patient experiences
without any S-T segment or T wave change are significant symptoms (e.g., palpitations). The
easily recognized. The development of unifocal best drug for the exercise-induced arrhythmias,
VPCs without an S-T, T wave abnormality including VPCs, is propranolol (Inderal).
 Case 63 / Diagnosis 145

CASE 63 He was unable to continue exercising be-

yond stage 3 of the exercise protocol because
A 57-year-old man was referred to a cardiol- of significant chest pain associated with fre-
ogist for evaluation of chest pain of 2 mos quent ventricular premature contractions
duration. His physical findings were unremark- (VPCs) and S-T segment alteration. His maxi-
able, and his 12-lead ECG was within normal mal heart rate was 146 beats per minute.
limits (not shown here). He was not taking
1. What is the exercise ECG diagnosis?
any drug other than sublingual nitroglycerin
2 .. What is its clinical significance?
(p.r.n.).

F
146 Ambulatory Electrocardiography

Diagnosis of a positive exercise ECG test. The diagnosis

Strips A are resting tracings. Strips Band C of coronary heart disease can be entertained
were recorded during exercise, whereas strips when coexisting horizontal or downsloping S-T
D through F are post-exercise tracings. segment depression of 1 mm or more, with or
The exercise BCG test is interpreted as defi- without typical anginal pain, is seen. Some
nitely positive, on the basis of a significant investigators have proposed that reproducibil-
horizontal to downsloping S-T segment depres- ity of typical anginal pain provoked by the
sion associated with frequent VPCs and chest same exercise workload is a highly reliable sign
pain during and after exercise. in the diagnosis of coronary artery disease even
Generally, exercise-induced multifocal VPCs when the diagnostic ECG finding is not pro-
and/ or grouped VPCs are strongly suggestive duced by the exercise testing.
 Case 64 / Diagnosis 147

CASE 64 tachyarrhythmias, although her resting heart

rate had always been rapid (120 to 140 beats
The Holter monitor EeG was obtained from per minute).
a 59-year-old woman who presented with fre-
1. What is the cardiac rhythm diagnosis?
quent episodes of palpitations. Routine 12-
2. What is the most likely underlying disorder?
lead electrocardiograms, taken on many occa-
3. What is the treatment of choice?
sions, failed to record any episode of ectopic
148 Ambulatory Electrocardiography

Diagnosis roidism. It is well known that sinus tachycardia,

even during a resting period, is very common
The strips A through C are not continuous. in patients with hyperthyroidism, with various
The underlying cardiac rhythm is sinus tachy- atrial tachyarrhythmias also frequently ob-
cardia with a rate of 138 beats per minute served. When working up any patient with per-
(strip A). The Holter monitor ECG docu- sisting sinus tachycardia, various disorders that
mented paroxysmal atrial tachycardia (rate: produce a high cardiac output (e.g., anemia,
200 beats per minute) initiated by atrial pre- beri-beri, A-V fistula) should be considered.
mature contractions (arrows) . In addition, The drug of choice for atrial tachycardia in
there is a ventricular premature contraction in hyperthyroidism is propranolol (Inderal). In
strip C (V). addition, the underlying disorder-hyperthy-
The patient was found to have hyperthy- roidism-should also be treated.
 Case 65 / Diagnosis 149

CASE 65 because of frequent ventricular premature con-

tractions (VPCs) associated with a significant
A 46-year-old man was referred to the Cardiac S-T segment depression. His maximal heart
Unit for evaluation of chest pain. He was not rate was only 103 beats per minute. A single
taking any drugs. His physical findings were channel (modified lead V 5) was utilized.
negative and his 12-lead BCG was within nor-
1. What is the exercise BCG diagnosis?
mal limits (not shown here).
2. What is its clinical significance?
He was unable to continue the exercise test-
ing beyond stage 2 of the exercise protocol
150 Ambulatory Electrocardiography

Diagnosis sloping S-T segment depression. It has been

Strip A is a resting tracing; strip B was re- well documented that ventricular arrhythmias,
corded during exercise. The remaining strips, particularly multifocal VPCs, grouped VPCs,
C through K, are post-exercise tracings. and VT provoked by minimal exercise (with
The patient developed frequent VPCs with less than 70% of the predicted maximal heart
paroxysmal ventricular tachycardia (VT) (V) rate) are highly suggestive of significant coro-
soon after the initiation of exercise; these were nary heart disease. The exercise ECG test was,
associated with a significant horizontal to down- of course, markedly positive.
 Case 66 / Diagnosis 151

CASE 66 1. What is the cardiac rhythm diagnosis during

rapid heart action?
A 40-year-old woman was seen in the Emer- 2. What is the treatment of choice?
gency Room because of extremely rapid heart 3. What is the 12-lead EeG diagnosis after
rate. She complained of palpitations associated termination of the rapid heart action?
with weakness. She told an Emergency Room
physician that she had experienced frequent
palpitations since childhood. She was not tak-
ing any drugs.
152 Ambulatory Electrocardiography

Diagnosis Quinidine or procainamide are equally effective

12-lead ECG (during paroxysm): The car- for prophylaxis. The mechanism that produces
diac rhythm is atrial fibrillation with anomalous tachyarrhythmias in the WPW syndrome has
A-V conduction, because of the Wolff-Parkin- been described in detail elsewhere (see Case
son-White (WPW) syndrome and an extremely 50).
rapid ventricular rate (rate: 160 to 250 beats
per minute). The ECG finding closely mimics 12-lead ECG (after paroxysm): The car-
ventricular tachycardia. diac rhythm is sinus with a rate of 100 beats
When the clinical situation is extremely ur- per minute. The diagnosis of the WPW syn-
gent, direct current shock should be applied drome, type A, is readily made on the basis of
immediately. Otherwise, the treatment of choice short P-R intervals with broad upright QRS
is an intravenous injection of lidocaine (Xylo- complexes in all precordial leads, as a result of
caine), which can block conduction through delta waves (see Case 48).
the accessory pathway in the WPW syndrome.
 Case 67 I Diagnosis 153

CASE 67 1. What is the 12-lead EeG diagnosis?

2. What is the Holter monitor EeG diagnosis?
This Holter monitor EeG was obtained from 3. What is the drug of choice?
a 47-year-old man because of frequent episodes
of rapid heart action. He was not taking any
drugs. His physical findings were unremark-
able.
154 Ambulatory Electrocardiography

Diagnosis is considered to represent reciprocating tachy-

12-lead ECG: The cardiac rhythm is sinus cardia (rate: 180 beats per minute) in the
with a rate of 85 beats per minute. If the WPW syndrome. The drug of choice for recip-
reader is familiar with the diagnostic criteria rocating tachycardia with normal QRS com-
of the WPW syndrome (see Case 48), it is plexes in the WPW syndrome is propranolol
readily apparent that the patient's ECG is (Inderal). For prophylaxis, propranolol may
diagnostic for the Wolff-Parkinson-White be prescribed in an oral dosage of 10 to 30
(WPW) syndrome, type A. mg, three to four times daily. The underlying
mechanisms for the production of tachyarrhyth-
Holter Monitor ECG: Rhythm strips A mias in the WPW syndrome have been de-
and B are not continuous. The cardiac rhythm scribed (Case 50).
diagnosis is supraventricular tachycardia, which
 Case 68 / Diagnosis 155

CASE 68 The exercise test was terminated prema-

turely at the end of the stage 3 because the
The exercise EeG test was requested for a 56- patient developed extremely rapid heart action.
year.:old man with a known WolfI-Parkinson-
1. What is the 12-lead EeG diagnosis?
White syndrome because he stated that his
2. What is the cardiac rhythm diagnosis on the
paroxysmal rapid heart action was often pre-
exercise EeG test?
cipitated by physical exercise. Interestingly
3. What is the treatment of choice?
enough, his paroxysmal heart action had never
been documented in spite of several 24-hr
Holter monitor recordings. He was not taking
any drugs.
156 Ambulatory Electrocardiography

Diagnosis As described earlier, direct current shock

12-1ead ECG: The cardiac rhythm is sinus should be applied immediately if the clinical
with a rate of 96 beats per minute. The ECG situation is extremely urgent. Otherwise, intra-
diagnosis is, obviously, the WPW syndrome, venous injection of lidocaine (Xylocaine) is
type A (see Case 48). the treatment of choice. For prophylaxis, oral
quinidine or procainamide are equally effective
Exercise ECG Test: Strips A and Bare for supraventricular tachyarrhythmias with
immediate post-exercise ECG tracings. The anomalous A-V conduction in the WPW syn-
cardiac rhythm is atrial fibrillation with inter- drome.
mittent anomalous A-V conduction as a result
of the WPW syndrome. The ventricular rate is
extremely rapid (125 to 200 beats per minute).
 Case 69 / Diagnosis 157

CASE 69 prematurely because of frequent ventricular

premature contractions (VPCs). The patient
A 54-year-old man was referred to a cardiol- was able to perform the exercise test up to
ogist for evaluation of his cardiac status. He stage 5. His maximal heart rate was 150 beats
had suffered a myocardial infarction (MI) 3 per minute.
mos earlier. The exercise ECG test was pri-
marily ordered to assess his functional capac- 1. What is the 12-lead ECG diagnosis?
ity. He was not taking any drugs. 2. What is the exercise ECG diagnosis?
The exercise testing was terminated a little
158 Ambulatory Electrocardiography

Diagnosis tricular ectopic beats (V), which has its own

12-1ead ECG: The cardiac rhythm is sinus ectopic cycle. Thus, the diagnosis of ventricu-
with a rate of 63 beats per minute. The diagno- lar parasystole can be made. It is interesting
sis of an old diaphragmatic MI is easily made to note that ventricular parasystole (V) per-
on the basis of Q or Q-S wave in leads III and sisted even after the VPCs disappeared com-
aVF. In addition, there is a nonspecific abnor- pletely (see leads V 5 and II of the last tracing).
mality of the S-T segment and T waves. The exercise ECG test is interpreted as
definitely positive on the basis of a significant
Exercise ECG Test: Strips A were taken S-T segment depression in addition to the fre-
during exercise, whereas strips B are post- quent VPCs produced by exercise. The clinical
exercise ECG tracings. Note the frequent VPCs significance of exercise-induced ventricular
with ventricular group beats. In addition to the parasystole is uncertain, however.
frequent VPCs, there is another form of ven-

B
Case 69 / Diagnosis 159
 Case 70 / Diagnosis 161

CASE 70 1. What is the cardiac rhythm diagnosis during

the rapid heart action?
A 24-year-old healthy man developed rapid 2. What is the disorder underlying this rapid
heart action; he had suffered from similar epi- heart action?
sodes previously. He was not taking any drugs. 3. What is the treatment of choice?

I
VI
V4

I
II

III V2
fffiffil

aVR • Vs

aVF
162 Ambulatory Electrocardiography

Diagnosis Propranolol (Inderal) is totally ineffective

12-1ead ECG (during paroxysm): The car- in such cases. Digitalis is not only ineffective,
diac rhythm appears to be ventricular tachy- but it also can enhance the anomalous A-V
cardia or even ventricular fibrillation (VF). conduction, leading to deterioration of the pa-
However, the correct diagnosis is atrial fibril- tient. In fact, this patient developed a true VF
lation with anomalous A-V conduction due to soon after the administration of digitalis, but
the Wolff-Parkinson-White (WPW) syndrome, fortunately, a defibrillator was used Imme-
type A. The ventricular rate is extremely rapid diately and sinus rhythm was restored.
(180 to 300 beats per minute), and the QRS
configuration is broad and bizarre. The diag- 12-1ead ECG (after paroxysm): The car-
nosis of the WPW syndrome, type A, is obvious diac rhythm is sinus arrhythmia with a rate of
during sinus rhythm. 55 to 70 beats per minute. The diagnosis of the
The treatment of choice is the immediate WPW syndrome, type A, is obvious (see Case
application of direct current shock (100 to 48). Note a pseudo-diaphragmatic and pos-
200 W-sec). When the clinical situation is not terior myocardial infarction pattern during
urgent, intravenous injection of lidocaine sinus rhythm because of the type A WPW
(Xylocaine) (50 to 100 mg) is the treatment syndrome.
of choice. For prophylaxis, oral quinidine or
procainamide (Pronestyl) are the drugs of
choice.

II

III

aVR

aVL
 Case 71 / Diagnosis 163

CASE 71 1. What is the cardiac rhythm diagnosis?

2. What is the treatment of choice?
These cardiac rhythm strips were obtained
from an 89-year-old woman with acute con-
gestive heart failure due to hypertensive heart
disease.
164 Ambulatory Electrocardiography

Diagnosis "coarse" AF (amplitude of the fibrillatory

The cardiac rhythm shows atrial fibrillation wave over 1 mm).
(AF) associated with left bundle branch block As far as the underlying disease is con-
with a very rapid ventricular response (ven- cerned, a fine AF is usually due to a coronary
tricular rate: 170 to 200 beats per minute). and/ or hypertensive heart disease, whereas a
In the differential diagnosis, ventricular tachy- coarse AF is nearly always found in patients
cardia, that is considered because of the rapid with rheumatic heart disease, and particularly
ventricular rate and bizarre and broad QRS in patients with mitral stenosis. Less com-
complexes, is definitely excluded on the basis monly, a coarse AF may be found in patients
of a grossly irregular ventricular cycle. In with hyperthyroidism.
elderly individuals, atrial fibrillatory waves are The patient was rapidly digitalized, with
usually not clearly evident and this finding is marked improvement.
termed "fine" AF to distinguish it from
 Case 72 / Diagnosis 165

CASE 72 1. What is the cardiac rhythm diagnosis before

treatment?
A 55-year-old man with chronic cor-pulmonale 2. What is the treatment of choice?
due to chronic obstructive pulmonary disease 3. What is the other BCG abnormality?
was admitted to the Coronary Care Unit be-
cause of advanced congestive heart failure asso-
ciated with rapid heart action.
166 Ambulatory Electrocardiography

Diagnosis The tracing taken after digitalization re-

The cardiac rhythm before treatment shows vealed a normal sinus rhythm with a rate of
atrial flutter (AFI) (atrial rate: 260 beats per 85 beats per minute.
minute) with a 2: I A-V response. Note that The striking abnormality in both EeG trac-
every other flutter wave is not conducted to ings is a tall R wave in lead V 1 due to right
the ventricles. ventricular hypertrophy. In addition, right
The treatment of choice for any supraven- atrial enlargement (P-pulmonale) is also pres-
tricular tachyarrhythmia, including AFI, asso- ent. The peaked and tall flutter waves in lead
ciated with congestive heart failure, is rapid V 1 represent right atrial enlargement.
digitalization. Digitalis is extremely effective in
such cases.
 Case 73/ Diagnosis 167

CASE 73 1. What is the cardiac rhythm diagnosis?

2. Which cardiac chamber is enlarged?
This ECG was taken on a 67-year-old man 3. What is the underlying disorder?
who has been taking digoxin (0.25 mg daily) 4. What is the direct cause of this rhythm
for several years. He was admitted to the disorder?
Coronary Care Unit because of progressive
congestive heart failure.

I
I I I IIII II I I II IIIIII

I I

1VR
II I II I I I
lVF
168 Ambulatory Electrocardiography

Diagnosis The tall R wave in lead V1 with right axis

The rhythm is multifocal atrial tachycardia deviation of the QRS complex (axis about
(MAT) (atrial rate: 175 beats per minute) +240 degrees) in limb leads is indicative of
(arrows) with a varying Wenckebach A-V right ventricular hypertrophy. The QRS vol-
block and an intermittent 2: 1 A-V block. Note tage shows generalized low voltage, which is
that the P-P cycles vary throughout the tracing. very common in patients with chronic cor-
The most common underlying disorder in pulmonale.
patients with MAT is chronic cor-pulmonale It should be noted that progressive conges-
due to chronic obstructive pulmonary disease, tive heart failure is one of the important signs
as is seen in this case. of digitalis intoxication.
Such a Wenckebach A-V block is usually The diagnostic criteria of MAT have been
due to digitalis intoxication. Here, chronic cor- described in detail (see Case 74).
pulmonale and digitalis intoxication together
are responsible for the MAT with A-V block.
 Case 74 / Diagnosis 169

CASE 74 1. What is the cardiac rhythm diagnosis?

2. What is the therapeutic approach of choice?
This electrocardiogram was obtained from an
86-year-old woman with chronic cor-pulmonale
due to chronic obstructive pulmonary disease.
170 Ambulatory Electrocardiography

Diagnosis this case. Less commonly, MAT is encoun-

The cardiac rhythm is multifocal atrial tachy- tered in patients with pulmonary embolism,
cardia (MAT) with a rate from 120 to 160 pneumonia, and hypoxia due to other causes.
beats per minute. Note the varying configura- This arrhythmia is occasionally observed post-
tions of the P waves with varying P-P cycles and operatively following various types of major
varying P-R intervals. In addition, some QRS surgery.
complexes are slightly bizarre because of aber- Note the peaking and the tall P waves indic-
rant ventricular conduction. ative of P-pulmonale.
The diagnostic criteria of multifocal atrial Multifocal atrial tachycardia has many other
tachycardia are as follows: names, such as chaotic atrial rhythm, chaotic
atrial tachycardia, chaotic atrial mechanism,
1. Two or more ectopic P waves with different
and malignant atrial tachycardia. As the names
configurations
of this arrhythmia indicate, MAT is difficult to
2. Two or more different ectopic P-P cycles
treat. Various anti-arrhythmic drugs have little
3. Atrial rates between 100 to 250 beats per
effect, although propranolol (Inderal) is effec-
minute (occasionally under 100 beats per
tive in some cases of MAT, providing there are
minute)
no contraindications. Improvement of the un-
4. An isoelectric line between P-P intervals
derlying pulmonary disease seems to be more
5. Frequent varying P-R intervals and an A-V
beneficial than the administration of any anti-
block of varying degree (non-conducted
arrhythmic drug. Occasionally, MAT may
ectopic P waves)
transform to atrial fibrillation or atrial flutter.
The underlying disorder in MAT is most
commonly chronic cor-pulmonale, as seen in
 Case 75 / Diagnosis 171

CASE 75 1. What is the cardiac rhythm diagnosis?

2. What is the treatment of choice?
A 51-year-old man visited the Cardiac Clinic
because of rapid heart action with a few hours'
duration. He was not taking any drugs.
172 Ambulatory Electrocardiography

Diagnosis In 80 to 85 % of the cases, the AVC exhibits

The cardiac rhythm is atrial fibrillation (AP) a right bundle branch block (RBBB) pattern.
with a very rapid ventricular response (rate: In the remaining 15 to 20%, aberrantIy con-
120 to 200 beats per minute) and frequent ducted beats may demonstrate a left bundle
aberrant ventricular conduction (AVC). A branch block pattern, or a left anterior or
consecutively occurring AVC closely mimics posterior hemiblock pattern. At times, AVC
paroxysmal ventricular tachycardia (VT). shows a bifascicular block (a combination of
The diagnosis of VT is definitely excluded a left anterior or posterior hemiblock and a
on the basis of the absence of post-ectopic RBBB) pattern, which is functional bifascicu-
pause and the presence of Ashman's phenom- lar block.
enon. Note the long ventricular cycle (R-R The treatment of choice is rapid digitaliza-
interval) immediately preceding the coupling tion.
interval (Ashman's phenomenon). Ashman's
phenomenon has been described in detail else-
where (see Case 5).
 Case 76 / Diagnosis 173

CASE 76 chronic cor-pulmonale. Digitalis toxicity was

suspected.
These EeG rhythm strips were obtained from
a 63-year-old woman with renal failure asso- 1. What is the cardiac rhythm diagnosis?
ciated with advanced congestive heart failure 2. What is the treatment of choice?
as a result of hypertensive heart disease and
174 Ambulatory Electrocardiography

Diagnosis Wenckebach A-V block are not obvious in this

Leads II, a through d are not continuous. EeG tracing primarily because the progressive
Note the P waves (arrows). The basic rhythm Wenckebach phenomenon is so slow.
is sinus tachycardia (arrows) (atrial rate: 102 Wenckebach A-V block or non-paroxysmal
beats per minute) with a slowly progressing A-V junctional tachycardia is extremely com-
Wenckebach A-V block. Non-paroxysmal A-V mon in digitalis intoxication. In addition, both
junctional tachycardia cannot be excluded in renal failure and chronic cor-pulmonale fre-
an early portion of the tracing because the P quently predispose to digitalis intoxication even
waves are not discernible. There is a strong when the patient is taking a smaller than usual
possibility, however, that the sinus P waves are dose.
superimposed on the QRS complexes of the The treatment of choice, of course, is the
preceding beat. The typical features of the immediate withdrawal of digitalis.

11-0
 Case 77 / Diagnosis 175

CASE 77 gency Room because of paroxysmal rapid heart

action.
These cardiac rhythm strips were obtained 1. What is the cardiac rhythm diagnosis?
from a 37-year-old black man with alcoholic 2. What is the treatment of choice?
cardiomyopathy. He was seen in the Emer-
176 Ambulatory Electrocardiography

Diagnosis A-V junction is implied. Thus, AFI with 2: 1

The cardiac rhythm reveals atrial flutter (AFl) A-V response is the correct diagnosis.
(atrial rate: 320 beats per minute) with a 2: 1 The immediate therapeutic approach is digi-
A-V response. Note that every other flutter talization. Sinus rhythm may be restored by
wave is not followed by QRS complexes. digitalization alone in many cases. When AF I
It can be said that AFI with a 2: 1 A-V persists after digitalization, however, and res-
response is one of the most common tachy- toration of sinus rhythm is desired, quinidine
arrhythmias seen in practice. Yet, it is often may be added. A combination of digitalis and
diagnosed as other arrhythmias, such as A-V quinidine may convert AFI to sinus rhythm
junctional tachycardia, supraventricular tachy- in many cases. When the clinical situation is
cardia, or even sinus tachycardia, when the considered very urgent, direct current (DC)
flutter waves are not recognized. shock should be applied immediately before
In AF 1 with a 2: 1 A-V response, the term digitalization. The efficacy of DC shock for
"response" is used instead of "block" because AFI is almost 100%. After restoration of
the 2: 1 A-V conduction in AFI is a physio- sinus rhythm by DC shock, many patients will
logic rather than a pathologic phenomenon. require digitalis with or without quinidine to
When the term "A-V block" is used, an ab- prevent the recurrence of AFI.
normally prolonged refractory period in the
 Case 78 / Diagnosis 177

CASE 78 1. What is the EeG diagnosis?

2. What is the treatment of choice?
A 55-year-old woman presented with Adams-
Stokes syndrome.

II -0

II -b

II -c

I -dlill
178 Ambulatory Electrocardiography

Diagnosis hemiblock. Thus, an intermittent complete

Leads II (a through d) are continuous. Note A-V block in this case is considered to be a
the sinus P waves (arrows) . The cardiac manifestation of an incomplete trifascicular
rhythm is sinus (arrows) (atrial rate: 70 beats block. In some areas, such as lead II d, a 2: 1
per minute) with an intermittent complete A-V block is closely mimicked. Intermittent
A-V block causing areas (leads II a and d) complete A-V block is called high-degree (ad-
of ventricular escape (idioventricular) rhythm vanced) A-V block.
(ventricular rate: 37 beats per minute). Permanent artificial pacemaker implantation
The configuration of the QRS complexes is the treatment of choice for symptomatic bi-
during normal sinus rhythm (leads II band fascicular or trifascicular block, particularly
c) shows a marked left axis deviation (QRS when advanced A-V block (intermittent com-
axis: -50 degrees, calculated from a 12-lead plete A-V block) is documented on other occa-
EeG), which is indicative of a left anterior sions.
 Case 79 / Diagnosis 179

CASE 79 1. What is the cardiac rhythm diagnosis?

2. What is the treatment of choice?
A 40-year-old woman with an atrial septal
defect was seen in the Emergency Room be-
cause of paroxysmal rapid heart action. She
was not taking any drugs.

E
180 Ambulatory Electrocardiography

Diagnosis duction (AVC) that occurs as the result of

Strips A through D, taken before treatment, Ashman's phenomenon (see Case 5). Ventric-
are continuous; strip E was recorded after ular tachycardia is closely mimicked during
treatment. The cardiac rhythm diagnosis before consecutive AVC.
treatment is probably atrial flutter (AFl) with Carotid sinus stimulation induced a tem-
a predominantly 1: 1 A-V conduction and an porary slowing of the ventricular rate in this
intermittent Wenckebach A-V conduction. The case-a characteristic feature of AFI. Rapid
API cycle is slower than usual (atrial rate: digitalization restored the sinus rhythm (strip
215 beats per minute) in this tracing, but the E).
typical sawtooth configuration of the flutter Surgical consultation was requested for pos-
waves is discernible at a slower ventricular rate. sible repair of the patient's atrial septal defect.
Note the consecutive aberrant ventricular con-
 Case 80 / Diagnosis 181

CASE 80 complain of any cardiac symptoms. He was not

taking any drugs. The 12-lead ECG showed
These cardiac rhythm strips were obtained, evidence of an old diaphragmatic MI.
during a routine visit to the Cardiac Clinic,
1. What is the cardiac rhythm diagnosis?
from an 80-year-old man with a previous myo-
2. What is the treatment of choice?
cardial infarction (MI). The physical findings
were unremarkable and the patient did not

E
182 Ambulatory Electrocardiography

Diagnosis multiple of the basic shortest inter-ectopic

Strips A through E (continuous lead II) show interval, the parasystolic cycle. There are many
a sinus rhythm (rate: 90 beats per minute), ventricular fusion beats, as would be expected.
but there is an intermittent slow ventricular Parasystolic VT is not uncommon in patients
tachycardia (VT) with a similar ventricular with acute or old MI, but the arrhythmia is
rate. usually self limiting. Thus, no treatment is
The diagnosis of parasystolic VT is made indicated. The usual rate of parasystolic VT is
on the basis of the fact that the long inter- 70 to 130 beats per minute.
ectopic interval that includes sinus beats is a
 Case 81 / Diagnosis 183

CASE 81 (A) was taken on admission, and another

ECG tracing (B) was taken on the following
A 69-year-old man was brought to the Emer- day, after treatment.
gency Room because of rapid heart action as-
sociated with mild congestive heart failure. He 1. What is the cardiac rhythm diagnosis?
was not taking any drugs. The EeG tracing 2. What is the treatment of choice?

• I
II

•
184 Ambulatory Electrocardiography

Diagnosis when the QRS morphology is identical during

In tracing A, the QRS complexes are broad ectopic tachycardia and during sinus rhythm.
and bizarre with no P waves, and the rhythm In this patient, the RBBB is the preexisting
is regular (rate: 160 beats per minute). It is ECG abnormality during sinus r;hythm (tracing
not absolutely certain whether this type of B), and many earlier ECG tracings showed
tachycardia represents ventricular tachycardia the same finding. Thus, the diagnosis of supra-
or supraventricular tachycardia with bundle ventricular, most likely paroxysmal A-V junc-
branch block or aberrant ventricular conduc- tional tachycardia (rate: 160 beats per min-
tion. ute) with RBBB is confirmed (tracing A).
To confirm the cardiac rhythm diagnosis, Tracing B shows a normal sinus rhythm
a comparison of the QRS configuration during (rate: 64 beats per minute) and RBBB. After
tachycardia and during sinus rhythm is ex- digitalization, sinus rhythm was restored in this
tremely important when earlier ECG tracings patient.
on the same patient are available. That is, a Carotid sinus stimulation was ineffective for
knowledge of the preexisting right or LBBB this tachycardia, but digitalization was suc-
during sinus rhythm is the determining factor cessful.
in the diagnosis of supraventricular tachycardia
 Case 82 / Diagnosis 185

CASE 82 1. What is the cardiac rhythm diagnosis?

2. What is the treatment of choice?
This BeG tracing was obtained from an 89-
year-old man with intractable congestive heart
failure. Digitalis intoxication was a possibility.
186 Ambulatory Electrocardiography

Diagnosis which is confirmed by the presence of constant

Note the P waves (arrows) . The cardiac R -R intervals (regular ventricular cycles) with
rhythm demonstrates atrial tachycardia (ar- changing P-R distances throughout the tracing.
rows) (atrial rate: 176 beats per minute) with Note the prominent U waves that indicate
an independent nonparoxysmal A-V junctional hypokalemia.
tachycardia (ventricular rate: 74 beats per Double supraventricular tachycardia is usu-
minute) producing a complete A-V dissocia- ally observed in patients with far-advanced
tion. Thus, this EeG finding is a good illustra- digitalis intoxication. Immediate discontinua-
tion of double supraventricular tachycardia. It tion of digitalis is the treatment of choice. When
should be noted that the atrial activity and the there is significant hypokalemia, administration
ventricular activity are completely independent, of potassium is beneficial.
 Case 83 / Diagnosis 187

CASE 83 1. What is the BCG diagnosis?

This BCG was obtained from a 65-year-old

man with coronary heart disease.
188 Ambulatory Electrocardiography

Diagnosis ventricles during their partial refractory period.

The rhythm is sinus with frequent atrial pre- When atrial bigeminy is established, the AVCs
mature contractions (APCs) producing atrial are more frequent because of Ashman's phe-
bigeminy. Note that the QRS complexes of the nomenon (see Case 5). In addition, there is a
APCs differ slightly in configuration from the preexisting right bundle branch block (RBBB).
sinus beats because of aberrant ventricular The QRS complexes of the APC, therefore, are
conduction (AVC), which occurs when the more bizarre because of AVC plus RBBB.
atrial ectopic impulses are conducted to the
 Case 84 I Diagnosis 189

CASE 84 1. What is the EeG diagnosis?

2. What is the mode of artificial pacing?
These cardiac rhythm strips were obtained
from a 64-year-old man with an artificial pace-
maker.
190 Ambulatory Electrocardiography

Diagnosis The cardiac rhythm disorder before implan-

The underlying rhythm is sinus (S) with a tation of the artificial pacemaker was a Mobitz
rate of 75 beats per minute. The diagnosis of type II A-V block (see Case 6). Note the con-
bifascicular block (BFB), which consists of stant P-R intervals in all conducted sinus beats
a right bundle branch block (RBBB) and a (S) until the blocked P waves occur. Thus,
left anterior hemiblock (LAHB) is easily this patient demonstrates a combination of a
made. An artificial pacemaker takes over the BFB, consisting of RBBB and LAHB, and a
ventricular activity whenever the basic cardiac Mobitz type II A-V block, an incomplete tri-
rhythm slows below the pre-set pacing rate. fascicular block. Note the occasional ventric-
This is a characteristic feature of the demand ular fusion beats (FB).
ventricular pacemaker.
 Case 85 / Diagnosis 191

CASE 85 episodes of paroxysmal rapid heart action. She

was not taking any drugs.
Cardiac rhythm strips were obtained from a
1. What is the cardiac rhythm diagnosis?
37-year-old woman with mitral valve prolapse
2. What is the drug of choice?
syndrome (MVPS). She experienced several
192 Ambulatory Electrocardiography

Diagnosis with frequent aberrant ventricular conduction

Strips a through c (lead II) are not continuous. of varying degrees, is readily recognized. Note
The underlying cardiac rhythm is sinus (the that the paroxysmal tachycardia is initiated by
first portion of lead II-a and the last portion an atrial premature contraction.
of lead II-b) with a rate of 75 beats per min- The drug of choice for various arrhythmias
ute. Paroxysmal supraventricular, a probable in the MVPS is propranolol (Inderal).
atrial tachycardia (rate: 167 beats per minute)
 Case 86/ Diagnosis 193

CASE 86 1. What is the cardiac rhythm diagnosis?

2. What is the other ECG abnormality?
This ECG tracing was obtained from an 82- 3. What is the treatment of choice?
year-old man with advanced congestive heart
failure as a result of coronary heart disease.
He was not taking any drugs.

11 • • • • •
194 Ambulatory Electrocardiography

Diagnosis culated from a 12-lead ECG), which represents

The cardiac rhythm is atrial fibrillation asso- a left anterior hemiblock (LAHB). Thus, this
ciated with right bundle branch block (RBBB) patient has a bifascicular block (incomplete
with a rapid ventricular response (ventricular bilateral bundle branch block) consisting of an
rate: 11 0 to 160 beats per minute). Again, RBBB and a LAHB.
ventricular tachycardia is superficially simu- In addition, a lateral myocardial infarction
lated because of a rapid ventricular rate with (MI) is suspected because of a small Q wave
bizarre and broad QRS complexes. A grossly with a markedly reduced R wave amplitude in
irregular ventricular cycle is the key in exclud- lead V 5. In fact, the patient had suffered an
ing a diagnosis of VT. MI3 mos earlier.
Another ECG abnormality is marked left The treatment of choice is rapid digitali-
axis deviation (QRS axis: -60 degrees, cal- zation.
 Case 87 / Diagnosis 195

CASE 87 1. What is the cardiac rhythm diagnosis?

2. What is the treatment of choice?
A 78-year-old woman presented with dizziness
and near-syncope and a Holter monitor EeG
was ordered. She was not taking any drugs.

D
196 Ambulatory Electrocardiography

Diagnosis tachyarrhythmia syndrome as a manifestation

Rhythm strips A through D are not continuous. of an advanced sick sinus syndrome.
The underlying cardiac rhythm is sinus brady- The treatment of choice is permanent artifi-
cardia and sinus arrhythmia, but there are cial pacemaker implantation. When the tachy-
intermittent atrial group beats and atrial tachy- arrhythmia component is not suppressed by
cardia. Note also frequent ventricular prema- artificial pacing, one or more anti-arrhythmic
ture contractions (V) with ventricular group drugs are indicated.
beats. These EeG findings represent a brady-
 Case 88 / Diagnosis 197

CASE 88 heart rate. He was not taking any drugs. He

complained of weakness and dizziness.
A 44-year-old man with a history of myocardial
infarction 2 mos earlier was seen in the Emer- 1. What is the cardiac rhythm diagnosis?
gency Room because of an extremely rapid 2. What is the treatment of choice?
198 Ambulatory Electrocardiography

Diagnosis VT does not produce a rate over 200 beats per

The cardiac rhythm is atrial flutter with a 1: 1 minute.
A-V conduction (rate: 250 beats per minute) The treatment of choice is immediate direct
and an aberrant ventricular conduction, which current (DC) shock. If DC shock is not avail-
occurs because the ventricular rate is extremely able, rapid digitalization is then the treatment
rapid. The bizarre and broad QRS complexes of choice. Alternatively, intravenous proprano-
mimic ventricular tachycardia (VT). As a rule, lol (Inderal) may be effective.
 Case 89 / Diagnosis 199

CASE 89 1. What is the cardiac rhythm diagnosis?

2. What is the treatment of choice?
A 70-year-old woman was admitted to the
Intermediate Coronary Care Unit because of
acute congestive heart failure. She was not
taking any cardiac drugs.

II

III
200 Ambulatory Electrocardiography

Diagnosis It is important, however, to digitalize after DC

The P waves are not discernible, but the ven- shock if congestive heart failure is present.
tricular cycles are regular and fast (ventricular Digitalis alone may convert AFI directly to
rate: 150 beats per minute). Whenever any sinus rhythm. At times, AF I may change to
BCG rhythm strip exhibits the above findings, atrial fibrillation (AF), which may remain for
atrial flutter (AFI) with a 2: 1 A-V response some time, or AF may finally convert to sinus
should be considered first. By close observa- rhythm. Not commonly, digitalis may simply
tion, the AFI waves can be seen, especially in increase the A-V conduction time, which pro-
lead II. In lead III, what appear to be ex- duces a slower ventricular rate (AFI with a
tremely rapid atrial waves occur, as the result 3:1 or a 4:1 A-V block). When AFI, or AF,
of the superimposition of the flutter waves and continues after digitalization, and the restora-
the T waves. Thus, the rhythm diagnosis of tion of sinus rhythm is considered to be
this rhythm strip is AFI (atrial rate: 300 beats definitely beneficial in a given patient, oral
per minute) with a 2: 1 A-V response. Un- quinidine therapy may be added. Practically,
treated AFI nearly always reveals a 2: 1 A-V however, many elderly patients do very well
response. The term "response" is used instead with AFI or AF as long as the ideal ventricular
of "block," in this case, because the 2: 1 A-V rate (rate: 60 to 80 beats per minute) is
conduction in AFI merely expresses a longer maintained. It is extremely important to deter-
physiologic refractory period in the A-V junc- mine whether restoration of the sinus rhythm
tion. Thus, the term 2: 1 A-V block is erroneous is truly beneficial to a given patient. The rea-
in AFI. son for this is that thromboembolic phenom-
Another common diagnostic error is A-V ena, particularly those resulting in cerebro-
junctional tachycardia because the AFI waves vascular accidents, are relatively common
appear to be inverted P waves, and every other during the first 24 to 72 hr after restoration
flutter wave may not be recognized. of sinus rhythm from AFI or AF by drugs or
The treatment of choice in this case is, ob- DC shock or both. It should be reemphasized
viously, rapid digitalization. When the clinical that AFI or AF with a reasonably well con-
situation is extremely urgent, direct current trolled ventricular rate is much better clinically,
(DC) shock may be applied immediately (25 in most cases, than sinus rhythm with a cere-
to 50 w-sec). The efficacy of DC shock is al- brovascular accident.
most 100%, with sinus rhythm being restored.
 Case 90 / Diagnosis 201

CASE 90 1. What is the cardiac rhythm diagnosis?

2. What is the treatment of choice?
These cardiac rhythm strips were obtained
from a 59-year-old woman who presented with
dizziness; they represent a continuous lead II.
She was not taking any drugs.

o
202 Ambulatory Electrocardiography

Diagnosis stance is strongly suggestive of a diseased A-V

Note the sinus P waves (arrows). The cardiac node.
rhythm is sinus with a 4: 1 A-V block and In strip D, the rhythm diagnosis is sinus
frequent ventricular escape beats (X) causing rhythm with a 2: 1 A-V block.
ventricular escape bigeminy (strips A through The mode of the A-V conduction disturb-
C). In other words, the sinus beats and the ance in this patient is most likely a variant of
ventricular escape beats alternate throughout a Mobitz type II A-V block. A permanent
the tracing. artificial pacemaker implantation is the treat-
Failure of the A-V junction to produce the ment of choice for symptomatic advanced A-V
expected escape impulses under this circum- block or Mobitz type II A-V block.
 Case 91 / Diagnosis 203

CASE 91 1. What is the cardiac rhythm diagnosis?

2. What is the treatment of choice?
A 70-year-old man with a permanent artificial
pacemaker was brought to the Emergency
Room because of syncope episodes.
204 Ambulatory Electrocardiography

Diagnosis In addition, the interval from the natural

The basic atrial mechanism is sinus but there beat to the subsequent pacing beat is much
is an independent, artificial pacemaker-induced longer than the consecutively occurring pacing
ventricular rhythm (rate: 70 beats per min- interval. This is termed "pacemaker hystere-
ute). Initially, ventricular fibrillation (VF) sis," which is a property of certain demand
appears to be related to the artificial pace- pacemaker models. An eady finding of a mal-
maker or indicative of a malfunctioning pace- functioning pacemaker, however, may be sus-
maker. With closer observation, however, it pected when hysteresis is marked.
becomes obvious that the VF was initiated by The treatment of choice is intravenous ad-
frequent ventricular premature contractions, ministration of lidocaine (Xylocaine). When
with ventricular group beats, and unrelated to VF persists, of course, immediate defibrillation
the artificial pacemaker. is the treatment of choice.
 Case 92 / Diagnosis 205

CASE 92 1. What is the cardiac rhythm diagnosis?

2. What is the treatment of choice?
These cardiac rhythm strips were obtained
from a 68-year-old man with several episodes
of syncope. The patient was not taking any
drugs.
206 Ambulatory Electrocardiography

Diagnosis SSS. But atrial pacing or coronary sinus pacing

Leads V1 (a through e) are continuous. The is more effective in the BTS, since the atrial
underlying cardiac rhythm is a very slow and tachyarrhythmia component is often suppressed
unstable sinus bradycardia (S) with a first- by atrial or coronary sinus pacing in up to
degree A-V block (P-R interval: 0.28 sec). 50% of the cases.
In addition, there are episodes of intermittent When there is a significant coexisting A-V
atrial fibrillation and atrial flutter (arrows) . conduction disturbance, however, a bifocal de-
These EeG findings are a good example of mand pacemaker provides the best pacing
brady-tachyarrhythmia syndrome (BTS) as a mode. A programmable pacemaker was recently
manifestation of the sick sinus syndrome (SSS). introduced. This type of pacemaker has proven
The treatment of choice is permanent pace- to be very useful in the treatment of BTS be-
maker implantation. cause the optimal pacing rate can be adjusted
As far as the mode of artificial pacing is at any time, noninvasively, on an individual
concerned, an ordinary demand ventricular basis.
pacemaker is adequate for most patients with
 Case 93/ Diagnosis 207

CASE 93 (e.g., excessive use of coffee, tea, 'or Coca-

Cola; heavy smoking).
A 37-year-old woman was referred to the Car- The Holter monitor ECG was obtained in
diac Unit because she had experienced an ir- order to document any cardiac arrhythmias
regular slow pulse from time to time. The that might underlie her complaint. Her resting
irregular pulse seemed to be related to physical 12-lead ECG was within norniallimits.
exercise. Her physical findings were entirely
1. What is the cardiac rhythm diagnosis?
unremarkable, and she was not taking any
2. What is the treatment of choice?
drugs. She denied any unusual personal habits
208 Ambulatory Electrocardiography

Diagnosis It has been shown that a Wenckebach A-V

12-lead ECG: The cardiac rhythm is sinus block may be encountered in apparently
with a rate of 98 beats per minute and the healthy, young individuals, and the finding is
tracing is within normal limits. considered to be insignificant clinically. Hyper-
active vagal tone has been considered a pos-
Holter Monitor ECG: Rhythm strips A sible cause.
through F are not continuous. Note the sinus Reassurance is sufficient in most cases, and
P waves (arrows). The cardiac rhythm diagno- no other treatment is necessary.
sis is sinus rhythm (rate: 83 beats per minute)
with an intermittent Wenckebach A-V block
of a varying A-V conduction ratio.

c
D

F
 Case 94 / Diagnosis 209

CASE 94 take of coffee or Coca-Cola. Her physical find-

ings were negative except for a normal preg-
Cardiology consultation was requested for a nancy. The resting 12-lead ECG was within
27-year-old, 4.5-mos pregnant woman because normal limits.
she complained of frequent palpitations. She
1. What is the cardiac rhythm diagnosis?
was not taking any drugs, and she denied any
2. What is the treatment of choice?
unusual personal habits, such as excessive in-
210 Ambulatory Electrocardiography

Diagnosis contractions and even short runs of ventricular

12-1ead ECG: The cardiac rhythm is sinus tachycardia. Aberrant ventricular conduction
with a rate of 75 beats per minute, and the has been described in detail elsewhere (see
ECG tracing is within normal limits. Case 5).
The treatment of choice is oral propranolol
Holter Monitor ECG: Rhythm strips A (Inderal) (10 mg, three to four times daily).
through D are not continuous. The underlying Various cardiac arrhythmias are not uncom-
cardiac rhythm is sinus (rate: 78 beats per mon during normal pregnancy, but the possi-
minute), but there are frequent atrial prema- bility of the Wolff-Parkinson-White syndrome,
ture contractions which lead to a paroxysmal mitral valve prolapse syndrome, or hyperthy-
atrial tachycardia (rate: 185 beats per min- roidism should always be considered in any
ute). In addition, it should be noted that there case of paroxysmal supraventricular tachyar-
is frequent aberrant ventricular conduction rhythmia in young individuals.
which closely resembles ventricular premature

D
 Case 95 / Diagnosis 211

CASE 95 drugs. Her resting 12-lead ECG revealed a

normal sinus rhythm (rate: 84 beats per min-
A 59-year-old woman was referred to a car- ute) and was within normal limits (not shown
diologist for evaluation of an intermittent slow here). The Holter monitor ECG was obtained
pulse rate associated with weakness. She re- in order to document the nature of the slow
called that she began to experience the above heart rate.
symptoms 3 yr earlier. Her physical findings
1. What is the cardiac rhythm diagnosis?
were unremarkable, except for mild hyperten-
2. What is the treatment of choice?
sion and slight obesity. She was not taking any

c
212 Ambulatory Electrocardiography

Diagnosis in any portion of the Holter monitor tracing.

The cardiac rhythm strips A through C are not Although a normal QRS complex is rather
continuous. Note the sinus P waves (arrows). unusual in Mobitz type II A-V block, the diag-
The diagnosis is sinus rhythm (atrial rate: 84 nosis is most likely Mobitz type II A-V block
beats per minute) with a Mobitz type II A-V in that the block may be in the His bundle
block and an intermittent 2: 1 A-V block (see itself, an intra-His block, which is a form of
strip B). During the 2: 1 A-V block, the ven- infra-nodal block.
tricular rate slowed greatly, and the patient A permanent demand ventricular pacemaker
became symptomatic. In over 75% of her implantation was carried out (see strip B), and
24-hr Holter monitor ECG tracing, the above- the patient improved markedly thereafter. Hy-
mentioned A-V block was documented. There drochlorothiazide (50 mg, every other day)
was no evidence of a Wenckebach A-V block was added for the mild hypertension.
 Case 96 / Diagnosis 213

CASE 96 one episode of syncope, she had been doing

well for her age. She was not taking any drugs.
A 71-year-old woman with coronary artery Physical findings were not remarkable.
disease was evaluated for the determination of
1. What is the EeG diagnosis?
the possible cause of a syncope episode. Other
2. What is the treatment of choice ?
than occasional nonspecific chest pains and
214 Ambulatory Electrocardiography

Diagnosis rhythm is sinus (rate: 56 to 75 beats per min-

12-lead ECG: The cardiac rhythm is sinus ute). An intermittent left bundle branch block
bradycardia with a rate of 56 beats per minute. (LBBB), of no clinical significance, was easily
The T waves are inverted in leads V1-3, which recognized. This EeG finding is not sufficient
suggests an anteroseptal myocardial ischemia. to explain her syncope episode, however. No
Another EeG abnormality is a possible left treatment is necessary for intermittent LBBB.
ventricular hypertrophy. No arrhythmia was Other possible causes for her syncope epi-
detected on a resting 12-lead EeG. sode should be investigated, and repeated Hol-
ter monitor EeG tracings should be obtained.
Holter Monitor ECG: Strips A through D
are not continuous. The underlying cardiac

o
 Case 97 / Diagnosis 215

CASE 97 On physical examination, she was found to

have a pansystolic murmur due to mitral in-
A 24-year-old woman with rheumatic heart sufficiency and left ventricular hypertrophy
disease was evaluated at the Cardiac Clinic (LVH). No evidence of congestive heart fail-
because of palpitations associated with dizzi- ure was detected, however.
ness. She had been taking prophylactic penicil-
1. What is the cardiac rhythm diagnosis?
lin, and she denied any unusual personal habits
2. What is the treatment of choice?
(e.g., smoking or excessive intake of coffee).
216 Ambulatory Electrocardiography

Diagnosis tachycardia (rate: 150 beats per minute) in

Rhythm strips leads VI, II, and Vs: The strip C.
underlying cardiac rhythm is sinus arrhythmia The diagnosis of brady-tachyarrhythmia
with intermittent sinus arrest leading to areas syndrome as a result of the sick sinus syndrome
of ventricular escape (idioventricular) rhythm (SSS) can be entertained from the above car-
(rate: 55 beats per minute). The other ECG diac rhythm analysis. Although the patient is
abnormality is LVH. young, a permanent artificial pacemaker im-
plantation should be seriously considered. Be-
Holter Monitor ECG: Strips A through D fore the pacemaker is implanted, however, it
are not continuous. Note the P waves (ar- should be ascertained whether her arrhythmias
rows), which have a different contour com- are transient in nature. Therefore, it is advis-
pared with the P waves shown on the cardiac able to observe her closely for several months,
rhythm strips (tracing A). Therefore, the un- with repeated Holter monitor ECGs, to con-
derlying cardiac rhythm is probably a wander- firm the true nature (transient versus perma-
ing pacemaker between the sinus node and the nent) of her arrhythmias.
A-V junction. In some areas (strips B and D), If her rhythm problem proves to be perma-
the ventricular rate is very slow (rate: 42 to nent, she should receive a permanent artificial
45 beats per minute) either during A-V junc- pacemaker implantation. In addition to artifi-
tional escape rhythm (strip D) or ventricular cial pacing, she may require one or more
escape (idioventricular) rhythm (strip B) . anti-arrhythmic drugs if the tachyarrhythmia
During ventricular escape rhythm, the underly- component is not suppressed by artificial pac-
ing cardiac rhythm disorder was considered to ing. It has been shown that rheumatic heart
be sinus arrest. In addition to the bradyarrhyth- disease is found to be a less common under-
mias, there was an episode of paroxysmal atrial lying cause of the SSS.
 Case 98 / Diagnosis 217

CASE 98 and his resting 12-lead BCG showed only rare

ventricular premature contractions (VPCs).
A 39-year-old man who had suffered a myo-
1. What is the 12-lead ECG diagnosis?
cardial infarction 6 mos earlier was referred
to a cardiologist for evaluation of an irregular 2. What is the Holter monitor EeG diagnosis?
3. What is the drug of choice?
cardiac rhythm. He was not taking any drugs,
218 Ambulatory Electrocardiography

Diagnosis beats per minute), but there are frequent multi-

12-lead ECG: The underlying cardiac focal VPCs with ventricular group beats. Since
rhythm is sinus arrhythmia with a rate of 56 his ventricular arrhythmias must be considered
to 68 beats per minute and there is a VPC. malignant and clinically significant, they should
The striking ECG abnormality is old diaphrag- be aggressively treated (see Tables 7 and 8).
matic-lateral myocardial infarction, which is The drug of choice is either quinidine or pro-
manifested by pathologic Q waves in leads II, cainamide. If these drugs are ineffective, pro-
III, aVF, and V5-6. pranolol (Inderal), diphenylhydantoin (Di-
lantin), or disopyramide (Norpace) should be
Holter Monitor ECG: The basic cardiac tried (see Table 6).
rhythm is sinus arrhythmia (rate: 65 to 96

D
 Case 99 / Diagnosis 219

CASE 99 1. What is the cardiac rhythm diagnosis?

2. What is the treatment of choice?
The Holter monitor BeG was requested on a
76-year-old man with coronary artery disease
because of palpitations associated with dizzy
spells. He was not taking any drugs.
220 Ambulatory Electrocardiography

Diagnosis mon in any ectopic tachycardia until it becomes

12-lead ECG: The underlying cardiac the stable rhythm. As a rule, the stable ectopic
rhythm is sinus with a rate of 62 beats per tachycardia will be manifested by faster heart
minute, and there is an atrial premature con- rates.
traction in leads aVR, aVL, and aVF. The The patient's ventricular arrhythmia should
evidence of diaphragmatic myocardial infarc- be aggressively treated because it is a malig-
tion is not obvious on this tracing, although nant ventricular arrhythmia (see Table 7).
the patient had a heart attack 1 yr earlier. In When the arrhythmia occurs frequently, or if
addition, left ventricular hypertrophy is sug- it persists, the patient should be treated in the
gested by voltage criteria. Coronary Care Unit or a similar facility where
a continuous ECG monitor is available. The
Holter Monitor ECG: Strips A and Bare treatment of choice is an intravenous injection
not continuous. The basic rhythm is sinus of lidocaine (Xylocaine) followed by an in-
(rate: 74 beats per minute), but there is an travenous infusion for 24 to 72 hr. Oral quini-
intermittent ventricular tachycardia (VT) dine, or procainamide, however, may be suffi-
(rate: 75 to 150 beats per minute). It should cient for prophylactic purposes when this
be noted that the ventricular cycle is grossly ventricular arrhythmia is observed only tran-
irregular during VT; this finding is not uncom- siently.

B
 Case 100 / Diagnosis 221

CASE 100 fully managed with cardiopulmonary resusci-

tative measures including four applications of
A 62-year-old man with a history of myocar- direct current (DC) shock. It is interesting
dial infarction (MI) about 4 to 6 wk earlier that his Holter monitor ECG and his resting
was referred to the exercise laboratory for 12-lead ECG failed to register any cardiac
assessment of his functional capacity. He was arrhythmia.
not taking any drugs, and he was symptom- 1. What is the 12-lead ECG diagnosis?
free at rest. 2. What is the result of the exercise ECG test?
With a moderate exercise workload (stage 3. What long-term therapeutic approach should
3 of the exercise protocol), he developed a be used?
cardiopulmonary arrest, which was success-
222 Ambulatory Electrocardiography

Diagnosis In tracing C, soon after the development of

12-lead ECG (tracing A): The cardiac VT, ventricular fibrillation (VF) occurred, and
rhythm is sinus with a rate of 95 beats per the patient became unconscious. A total of
minute. The evidence of an extensive anterior four applications of DC shock were required
myocardial infarction (MI), as well as a dia- to terminate VF. Strip A was taken during VF,
phragmatic MI, is easily recognized. and strip B was obtained following the ter-
mination of VF.
Exercise ECG test (tracings B and C): The
strips A and B were taken at rest in the supine Holter Monitor ECG: Strips A through
and the standing position, respectively. Strips C are not continuous. The rhythm is sinus
C and D were recorded during exercise, when (rate: 80 beats per minute) with no evidence of
the patient developed ventricular tachycardia cardiac arrhythmia.
(VT) (rate: 210 beats per minute) initiated For long-term therapy, the patient should
by a ventricular premature contraction with be placed on maintenance oral quinidine or
the R-on-T phenomenon. procainamide indefinitely.

Tracing A
 Case 100 / Diagnosis 223

TracingB

c
TracingC
Appendix
Table 1
DYNAMIC ELECTROCARDIOGRAPHY®
TIME ACTIVITY SYMPTOMS

PATIENT ACTIVITY DIARY

D1OHr. 012 Hr. f8124 Hr. D26Hr.

Patient's Name: f"Bml ~,fA,

Patient's Address: /.J!J 74atm ~t1t:
PhiPadofft',.,) {Ja" ,q 10 I
Age:.s..:L Sex:M- Phone: 555 -/.2. /tL
Medication: s#p,~,.a1.
Doctor: l'J,udlff Phone: t},.p.9-,t,JAtJ
Hospital: ~, I ?{. Room:.sJ,Ji

Date of Recording: 7/1/13 Started: 10:00 ~

Connected by: P.roAi
228 Ambulatory Electrocardiography

Table 2 Indications for the Use of the Ambula- Table 5 Factors Influencing the Therapeutic
tory (Holter Monitor) ECG Approach

1. Diagnosis of cardiac arrhythmias 1. Physician's philosophy, medical background, and

2. Evaluation of symptoms (e.g., dizziness, fainting, experience
palpitation) to correlate with actual arrhythmias 2. Symptomatic arrhythmias versus asymptomatic ar-
3. Diagnosis of myocardial ischemia rhythmias
4. Evaluation of anti-arrhythmic drug therapy 3. Clinical circumstances (e.g., myocardial ischemia,
5. Evaluation of artificial pacemaker function health of individual, digitalis intoxification)
4. Mechanisms of arrhythmias
5. Acute arrhythmias versus chronic arrhythmias

Table 3 Value of the Holter Monitor ECG versus

the Exercise ECG
Table 6 The Therapeutic Approach to Cardiac
Holter Arrhythmias
Monitor Exercise
ECG ECG 1. Eliminate the cause if possible
2. Anti-arrhythmic drug therapy
Cardiac arrhythmias +++ + Digitalis
Myocardial ischemia + +++ Lidocaine (Xylocaine)
Evaluation of symp- +++ +++ Pronestyl (procaine amide)
toms ( dizziness, (chest pain) Quinidine
fainting, Inderal (propranolol)
palpitations) Norpace (disopyramide phosphate)
Evaluation of drug + ++ Dilantin (diphenylhydantoin)
efficacy Sedatives
Evaluation of artificial + 3. Direct current shock
pacemaker 4. Artificial pacemaker
Morbidity and + 5. Surgery
mortality 6. Any combination of the above
Cost ($) 100-150 100-125

Key: +++, extremely useful;

++, significantly useful; Table 7 Cardiac Arrhythmias Requiring Treat-
+, moderately useful; ment
-, no value.
1. Symptomatic arrhythmias (e.g., dizziness, syncope,
palpitations)
Table 4 Interpretations of the Ambulatory 2. Malignant ventricular arrhythmias
(Holter Monitor) ECG 3. Sick sinus syndrome and brady-tachyarrhythmia
syndrome
1. Describe the basic cardiac rhythm 4. Symptomatic bilateral bundle branch block (bi-
2. Describe any cardiac arrhythmias fascicular or trifascicular block)
3. Describe the relationship between the arrhythmia 5. Infra-nodal A-V block (Mobitz type II and com-
and physical activity or complaints plete trifascicular block)
4. Evaluate the symptoms (e.g., palpitation, dizzi- 6. Persisting, exercise-induced arrhythmias
ness) and correlate them with the actual arrhyth-
mias
5. Describe the ischemic ECG change and correlate
them with physical activity and chest pain
6. Conclusion (e.g., clinically significant versus clini-
cally insignificant)
 Appendix 229

Table 8 Malignant Ventricular Premature Con- Table 10 Diagnostic Criteria of Bilateral Bundle
tractions Branch Block

1. Symptomatic 1. Right bundle branch block with left anterior hemi-

2. In acute myocardial infarction block
3. In digitalis toxicity 2. Right bundle branch block with left posterior hemi-
4. Ventricular premature contractions with the R-on-T block
phenomenon 3. Alternating left and right bundle branch block
5. Multifocal ventricular premature contractions 4. Left or right bundle branch block with first-degree
6. Grouped ventricular premature contractions or second-degree A-V block
7. Ventricular premature contractions induced by mild 5. Left or right bundle branch block with a prolonged
exercise (less than 70% of maximal heart rate) H-V interval (>70 msec)
8. Persisting, exercise-induced ventricular premature 6. Left bundle branch block on one occasion, right
contractions bundle branch block on another
9. Frequent (over 30 beats per hour) ventricular pre- 7. Mobitz type II A-V block
mature contractions 8. Any combination of the above
9. Complete A-V block with ventricular escape
rhythm

Table 9 Electrocardiographic Manifestations of

the Sick Sinus Syndrome
Table 11 Benign Ventricular Arrhythmias
1. Marked sinus bradycardia, sinus arrest, S-A block
2. Drug (atropine, Isuprel)-resistant sinus bradyar- 1. Occasional unifocal ventricular premature contrac-
rhythmias tions «30 beats per hour)
3. Long pause following an atrial premature contrac- 2. Asymptomatic ventricular premature contractions
tion in healthy individuals
4. Long sinus node recovery time by atrial pacing 3. Right ventricular premature contractions
(>1500 msec) 4. Ventricular parasystole and parasystolic ventricu-
5. Atrial fibrillation lar tachycardia
a) with slow ventricular rate 5. Non-paroxysmal ventricular tachycardia (accel-
b) preceded or followed by sinus bradycardia and! erated idioventricular rhythm)
or first-degree A-V block
6. First-degree A-V block (P-R interval ~ 0.28 sec)
7. A-V junctional escape rhythm (with or without
slow, unstable sinus activity)
8. Brady-tachyarrhythmia syndrome
9. Any combination of the above
Conclusion
Holter monitor electrocardiography (ambula- 11. The Holter monitor EeG is particularly
tory electrocardiography) is one of the most useful for the diagnosis of sick sinus syn-
commonly used noninvasive diagnostic methods drome (SSS).
in the field of cardiology. The uses of Holter 12. The most common complaints which re-
monitor electrocardiography can be sum- quire the Holter monitor EeG are dizzi-
marized as follows: ness or episodes of fainting spells.
13. The common manifestations of SSS include
periods of marked sinus bradycardia, sinus
1. Assessment of transient or paroxysmal arrest, S-A block, A-V junctional escape
cardiac arrhythmias. rhythm and atrial flutter or fibrillation with
2. Evaluation of various symptoms (e.g., diz- advanced A-V block.
ziness, syncope, palpitations); correlation 14. At present, the most common indication
with actual arrhythmias. for permanent artificial pacemaker implan-
3. Diagnosis of transient myocardial ischemia; tation is SSS.
evaluation of anti-arrhythmic drug therapy 15. Holter monitor EeG is extremely impor-
and artificial pacemaker function. tant to document advanced bilateral bun-
4. In interpretation of the Holter monitor dle branch block (BBBB) in order to
EeG, the basic cardiac rhythm should be determine the indication vs. non-indication
first described. of permanent artificial pacemaker.
5. Any cardiac arrhythmia detected by the 16. Brady-tachyarrhythmia syndrome (BTS)
Holter monitor EeG should be described is often documented by the Holter monitor
in relation to the patient's symptoms and EeG, and BTS almost always requires
physical activities. permanent pacemaker implantation.
6. When any ischemic change occurs on the 17. SSS is the most common underlying dis-
Holter monitor EeG, the EeG finding order to produce BTS.
should be correlated with the patient's 18. Holter monitor EeG is very essential to
complaint (particularly chest pain) and document paroxysmal tachyarrhythmia in
physical activities. the Wolff-Parkinson-White (WPW) syn-
7. When any cardiac arrhythmia is detected drome, because the rapid heart action in
on the Holter monitor EeG, it should be this syndrome is often transient.
mentioned whether a given arrhythmia is 19. The efficacy of digitalis for atrial fibrilla-
clinically significant or insignificant. tion is best evaluated by the Holter moni-
8. At present, the Holter monitor EeG tor EeG to correlate with the patient's
equipment has the capability to record the activity, because well-controlled ventricu-
EeG for 24 hours, but the old models can lar rate at rest may accelerate markedly
record only 10 or 12 hours. during various physical activities. Under
9. A diary card must be completed by the this circumstance, the dosage of digitalis
patient, and detailed descriptions regard- may be increased or additional drug such
ing symptoms in relation to the physical as propranolol (lnderal) may be pre-
activities must be given. A recording of scribed.
the precise time of each event is essential. 20. Various artifacts must be carefully searched
10. Newer models have a capability of record- in order to avoid possible misinterpreta-
ing 2 channels (2 EeG leads) but older tion of the artifact-induced EeG findings
models can record only one EeG lead. as true cardiac arrhythmias.

233
Suggested Readings
BLEIFER, S. B., BLEIFER, D. I., HANSMANN, D., raphy, American Heart Association, Recom-
and SHEPPARD, I. I.: Diagnosis of occult mendations for standardization of leads and
arrhythmias by Holter electrocardiography. specifications for instruments in electrocardiog-
Progr. Cardiovasc. Dis. 16:569 (1974). raphy and vectorcardiography. Circulation 35:
BLEIFER, S. B., KARPMAN, H. L., SHEPPARD, I. I., 583 (1967).
and BLEIFER, D. J.: Relation between prema- LAROSA, J. C., BROWN, W. V., FROMMER, P. L.,
ture ventricular complexes and development of and LEVY, R. I.: Clofibrate-induced ventricular
ventricular tachycardia. Am. I. Cardiol. 31:400 arrhythmia. Am. I. Cardio!. 23:266 (1969).
(1973). LIpSKI, J., COHEN, L., ESPINOZA, J. et al.: Value
CHUNG, E. K.: Electrocardiography: Practical Ap- of Holter monitoring in assessing cardiac ar-
plications with Vectorial Principles, 2nd Ed. rhythmias in symptomatic patients. Am. I.
Hagerstown, Md.: Harper & Row, 1979. Cardiol. 37:102 (1976).
CHUNG, E. K.: Exercise Electrocardiography: LOWN, B., TYKOCINSKI, M., GARFEIU, A., and
Practical Approach. Baltimore: Williams & BROOKS, P.: Sleep and ventricular premature
Wilkins, 1979. beats. Circulation 48:691 (1973).
CHUNG, E. K.: Artificial Cardiac Pacing: Prac- SIMBORG, D. W., Ross, R. S., LEWIS, K. B., and
tical Approach. Baltimore: Williams & Wilkins, SHEPARD, R. H.: The R-R interval histogram.
1979. A technique for the study of cardiac rhythms.
CHUNG, E. K.: Principles oj Cardiac Arrhythmias, I.A.M.A. 197:145 (1966).
2nd Ed. Baltimore: Williams & Wilkins, 1977. STERN, S. and TZIVONI, D.: Early detection of si-
CHUNG, E. K.: Wolff-Parkinson-White syndrome: lent ischemic heart disease by 24-hour electro-
Current views. Am. I. Med. 62:252 (1977). cardiographic monitoring of acute subjects.
CHUNG, E. K.: Digitalis Intoxication. Amsterdam: Br. Heart 1.36:481 (1974).
Excerpta Medica, 1969. STERN, S. and TZIVONI, D.: Dynamic changes in
DEBUSK, R. F.: The role of ambulatory monitor- the ST-T segment during sleep in ischemic
ing in post-infarction patients. Heart and Lung heart disease. Am. I. Cardiol. 32:17 (1973).
4:555 (1975). STERN, S. and TZIVONI, D.: The reliability of the
HARRISON, D. C., FITZGERALD, J. W., and WINKLE, Holter-Avionics system in reproducing the
R. A. : Ambulatory electrocardiography for ST-T segment. Am. Heart I. 84:427 (1972).
diagnosis and treatment of cardiac arrhyth- WEINBERG, S. L.: Observations on ambulatory
mias. New Engl. I. Med. 294:373 (1976). electrocardiographic monitoring in clinical
IYENFAR, R., CASTELLANOS, A., and SPENCE, M.: practice. Heart and Lung 4:546 (1975).
Continuous monitoring of ambulatory patients WEISBERGER, C. L. and CHUNG, E. K.: Holter
with coronary disease. Progr. Cardiovas. Dis. monitor electrocardiography. In: Non-Invasive
13:392 (1971). Cardiac Diagnosis (Edward K. Chung, ed.).
KOCH-WESER, I.: Antiarrhythmic prophylaxis of Philadelphia: Lea & Febiger, 1976.
ambulatory patients with coronary heart dis- WINKLE, R. A., LOPES, M. G., FITZGERALD, J. W.
ease. Arch. Intern. Med. 129:763 (1972). et aI.: Arrhythmias in patients with mitral valve
KOSSMAN, C. E., BRADY, D. A., BURCH, G. E. prolapse. Circulation 52:73 (1975).
et al.: Report of committee on electrocardiog-

237
Index
A Atrial fusion beats, Case 60
Aberrant ventricular conduction, Cases 5, 7, Atrial parasystole, Case 11
27, 33, 36, 53, 75, 85, 88 Atrial premature contractions, Cases 8, 17, 33, 34,
Advanced A-V block, Cases 29,31,78,84,90 35,39, 64, 83, 85
Aldomet, Case 10 Atrial tachycardia. See Paroxysmal atrial tachy-
Ambulatory ECG (Tables) cardia
Arrhythmias requiring treatment. See Table Atrial tachycardia, multifocal, Cases 73 and 74
7 Atromid S-induced arrhythmias, Case 39
Benign ventricular arrhythmias. See Table 11 A-V block. See specific type and degree of A-V
Diagnostic criteria of bilateral bundle branch block
block. See Table 10 A-V dissociation, Cases 24, 45, 82
ECG manifestations of sick sinus syndrome. A-V junctional arrhythmias, See A-V premature
See Table 9 contraction; Atrial tachycardia, multifocal;
Indications. See Table 2 A-V junctional escape beats or rhythm
Interpretation. See Table 4 A-V junctional escape beats or rhythm, Cases 24,
Malignant ventricular premature contrac- 60
tions. See Table 8 A-V junctional parasystole, Case 53
Therapeutic approach. See Tables 5 and 6
Value. See Table 3 B
Angina pectoris. See Myocardial injury; Myocard- Barlow's syndrome. See Mitral valve prolapse syn-
ial ischemia drome
Anxiety and arrhythmias, Case 21 Bifascicular block, Cases 43, 84, 86
Arrhythmias. See specific arrhythmias; see also In atrial fibrillation, Case 86
Tables 1-11 Functional, Case 75
Arrhythmias in mitral valve prolapse syndrome. Bilateral bundle branch block. See also Bifascic-
See Mitral valve prolapse syndrome ular block; Trifascicular block
Arrhythmias in myocardial infarction. See Myo- Diagnostic criteria. See Table 10
cardial infarction; see also specific arrhythmias Blocked atrial premature contractions, Case 34
Arrhythmias in pregnancy, Case 94 Brady-tachyarrhythmia syndrome. See also Sick
Artificial pacemaker, Cases 9, 20, 43, 44, 46, 78, sinus syndrome, Cases 3, 8, 12, 14, 25, 27, 28,
84,87,90,91,92,95 29,30,32,87,92,97
Demand veI)tricular pacemaker, Cases 9, 20,
46 C
Hysteresis, Case 91 Cardiac arrest, Case 100
Malfunction, Cases 9, 47 Cardiopulmonary resuscitation, Case 100
Pseudo-malfunction, Case 91 Chronic cor-pulmonale, Cases 72, 74, 76
Ashman's phenomenon, Cases 5, 27, 33, 75 Chronic obstructive pulmonary disease, Cases 72,
Atrial arrhythmias. See Atrial fibrillation; Atrial 74, 76
flutter, Atrial premature contractions; Atrial Complete A-V block, Case 45
tachycardia, multifocal Congestive heart failure, Cases 5, 16, 71, 72, 75,
Atrial bigeminy, Cases 33, 34, 83 76, 77, 79, 82, 86, 89
Atrial fibrillation, Cases 3, 4, 5, 12, 16, 27, 28, 29, Coronary heart disease. See also Myocardial in-
30, 31, 37,38, 56, 66, 68, 70, 71, 75, 86, 92 farction; Myocardial ischemia, Cases 14, 17,
With aberrant ventricular conduction, Cases 37, 39, 41, 55, 56, 57, 59, 65, 69, 88, 98, 100
5, 75
Coarse, Case 5 D
Exercise-induced, Case 68 Delta wave. See Wolff-Parkinson-White syndrome
With left bundle branch block, Case 71 Dextrocardia, Case 59
With right bundle branch block, Case 86 Diagrams
In Wolff-Parkinson-White syndrome, Cases Reciprocating tachycardia in the Wolff-
66,68, 70 Parkinson-White syndrome, Case 50
Atrial flutter, Cases 27, 36, 72, 77, 79, 88, 89, 92 Wolff-Parkinson-White syndrome, Case 48
With aberrant ventricular conduction, Cases Diary card. See Table 1
36,79,88 Digitalis intoxication, Cases 45, 73, 76, 82
With 1: 1 A-V conduction, Cases 36, 79, 88 Digitalization, Cases 5, 16, 37, 38, 56, 75, 81, 86,
With 2:1 A-V conduction, Cases 72, 77, 89 88,92
With Wenckebach A-V response, Case 79 Direct current shock, Cases 70, 88, 100

239
240 Index

Dizziness, Cases 8, 14, 28, 29, 32 Myocardial infarction, Cases 3, 4, 9, 20, 43, 98,
Double supraventricular tachycardia, Case 82 100
Associated with ventricular tachycardia and
E fibrillation, Case 100
Exercise ECG test, Cases 56, 57, 58, 59, 60, 61, With bifascicular block, Case 43
62, 63, 64, 65, 68, 69, 100 With bundle branch block, Case 43
Value. See Table 3 With Mobitz type II A-V block, Case 43
Exercise-induced arrhythmias. See Exercise ECG Myocardial injury, Case 55
test Myocardial ischemia, Cases 14, 37
Multifocal atrial tachycardia, Cases 73, 74
F With A-V block, Case 73
Fainting, Cases 13, 26, 27, 28, 29, 32, 43, 44
First degree A-V block, Cases 32, 61, 92 N
Digitalis-induced, Case 76 Near-syncope, Cases 10, 12
Exercise-induced, Case 61 Non-conducted atrial premature contractions, Case
In sick sinus syndrome, Case 92 34
Fusion beats. See Atrial fusion beats; Ventricular Non-paroxysmal A-V junctional tachycardia, Case
fusion beats 82

G o
Group beats. See specific atrial and ventricular Obesity, Case 18
group beats
p
H Pacemaker hysteresis, Case 91
Hemiblocks. See Left anterior hemiblock Palpitations, Cases 2, 7, 15, 17, 21, 35, 36, 85
High degree A-V block. See Advanced A-V block Parasystole, Cases 14, 53, 54, 80
Holter monitor ECG. See Ambulatory ECG Parasystolic ventricular tachycardia, Case 80
Hypertension, Cases 10, 15, 68 Paroxysmal atrial tachycardia, Cases 7, 8, 13, 17,
Hypertensive heart disease, Cases 1, 16 21, 35, 36, 39, 64, 73, 85, 87, 94, 97
Hyperthyroidism, Case 64 With aberrant ventricular conduction, Cases
Hysteresis. See Pacemaker hysteresis 7, 36, 85
With A-V block, Case 73
I Exercise-induced, Case 64
Inderal. See Propranolol In digitalis intoxication, Case 73
Infra-nodal A-V block, Cases 43, 84, 90 In hyperthyroidism, Case 64
Intra-His A-V block, Case 95 With non-paroxysmal A-V junctional tachy-
Intraventricular blocks. See Bifascicular block; cardia, Case 82
Left anterior hemiblock; Left bundle branch In pregnancy, Case 94
block; Right bundle branch block; Trifascicular P-pulmonale, Case 72
block Procainamide (Pronestyl), Cases 32, 41, 68, 98,
Irregular pulse, Cases 6, 93 99
Propranolol (Inderal), Cases 7, 13,21,35,36,50,
L 64, 67, 85, 94
Left anterior hemiblock, Cases 32, 51, 86 Pseudo-myocardial infarction, Case 70
Associated with Mobitz type II A-V block,
Cases 43,84 Q
Associated with right bundle branch block, Quinidine, Cases 32, 41, 98, 99
Cases 43, 84,86
Intermittent, Case 51 R
Left bundle branch block, Cases 4, 13,31,52,58, Renal failure, Case 76
71,96 Rheumatic heart disease, Cases 5, 97
Associated with atrial fibrillation, Case 71 Right bundle branch block, Cases 8, 10, 12, 43,
Exercise-induced, Case 58 83, 84
Intermittent, Cases 4, 52, 96 Associated with hemiblock, Cases 43, 84, 86
Left ventricular hypertrophy, Cases 1, 3, 4, 12, Associated with Mobitz type II A-V block,
15, 16, 58, 83 Cases 43, 84
Lidocaine, Cases 42, 66, 68, 70, 99 Right ventricular hypertrophy, Case 72
R-on-T phenomenon, Case 91
M
Malfunction of pacemaker. See Artificial pace- S
maker, Malfunction Second degree A-V block. See Mobitz type II A-V
Mitral valve prolapse syndrome, Cases 19, 40, 85 block; 2: 1 A-V block; Wenckebach A-V block
Mobitz type I A-V block. See Wenckebach A-V Sick sinus syndrome, Cases 3, 12, 23, 24, 25, 26,
block 27, 28, 29, 30, 31, 32, 46, 87, 92, 97
Mobitz type II A-V block, Cases 20, 43, 78, 84, ECG manifestations. See Table 9
95 In rheumatic heart disease, Case 97
 Index 241

Sino-atrial block, Case 23 Ventricular pre-excitation syndrome. See Wolff-

Sinus arrest, Cases 46, 97 Parkinson-White syndrome
Sinus arrhythmia, Cases 22, 24 Ventricular premature contractions, Cases 1, 2, 6,
Sinus bradycardia, Cases 10, 14, 24, 25, 26, 28, 11, 15, 17, 18, 19,22, 24, 25, 27, 28, 29, 30,
32, 87, 92, 97. See also Sick sinus syndrome 32,39,40,41,87,91,94,98
Aldomet-induced, Case 10 Benign. See Table 11
Smoking-induced arrhythmias, Case 18 Bigeminy, Cases 1, 11, 98
Stress ECG test. See Exercise ECG test Exercise-induced, Cases 56, 57, 59, 62, 63
Supraventricular tachycardia, Cases 13, 81 Grouped, Cases 2, 6, 11, 15, 18, 19,29, 30,
Double, Case 82 41, 63, 87, 91, 94, 98
With right bundle branch block, Case 81 Interpolated, Case 22
Syncope, Cases 3, 13. See also Fainting; Near- Malignant. See Table 8
syncope Multifocal, Cases 2, 6, 11, 15, 32, 41, 56,
63, 91, 98
T Trigeminy, Cases 39,40
Tables. See Ambulatory ECG Ventricular tachycardia, Cases 14, 32, 42, 65, 69,
Third degree A-V block. See complete A-V block 99
Thyrotoxicosis, Case 60 Exercise-induced, Cases 65, 69, 100
Treadmill test. See Exercise ECG test Parasystolic, Case 80
Treatment of arrhythmias. See Artificial pace-
maker; Digitalization; Direct current shock; W
Lidocaine; Procainamide; Propranolol; Quini- Wandering atrial pacemaker, Cases 22, 60
dine Wenckebach A-V block, Cases 6, 44, 76, 93
Trifascicular block, Cases 43, 84, 90 In atrial flutter, Case 79
Two-to-one A-V block, Cases 43, 44, 90, 95 Digitalis-induced, Cases 73, 76
In healthy individuals, Case 93
V Wolff-Parkinson-White syndrome, Cases 48, 49,
Ventricular arrhythmias, Tables 8 and 11. See 50, 66, 67, 68, 70
also Ventricular fibrillation; Ventricular pre- Atrial fibrillation in, Cases 66, 68, 70
mature contractions; Ventricular tachycardia; Diagram, Case 48
Ventricular escape beats or rhythm Intermittent, Cases 48, 50
Ventricular escape beats or rhythm, Cases 3, 8, Multiple anomalous pathways, Case 49
12, 26, 28, 30, 78, 90, 97 Reciprocating tachycardia in, Cases 50, 67
Ventricular fibrillation, Cases 91, 100 Treatment. See Digitalization; Direct current
Exercise-induced, Case 100 shock; Lidocaine; Procainamide; Pro-
In patients with artificial pacemaker, Case 91 pranolol; Quinidine
Ventricular fusion beats, Cases 20, 46, 80
Ventricular parasystole, Cases 14, 54, 69, 80 X
Ventricular parasystolic tachycardia, Case 80 Xylocaine. See Lidocaine