Wolff-Parkinson-White Syndrome

Treat an irregular wide-QRS tachycardia with beat-to-beat variation in QRS morphology and very rapid ventricular activation as pre-excited atrial fibrillation until an alternative diagnosis is established. In this setting, rapid antegrade conduction through the accessory pathway can produce ventricular rates capable of degenerating into ventricular fibrillation. jacc+1jaccAtrial Fibrillation in Wolff-Parkinson-White Syndrome | JACC: Case ReportsacpjournalsLidocaine in Wolff-Parkinson-White Syndrome with Atrial Fibrillation

Measure the shortest pre-excited RR interval on the presenting ECG when discernible. A shortest interval below 250 ms during atrial fibrillation predicts increased risk of ventricular fibrillation; a reported interval of 160 ms represents particularly rapid accessory-pathway conduction. jacc+1jaccAtrial Fibrillation in Wolff-Parkinson-White Syndrome | JACC: Case ReportsWileyWolff‐Parkinson‐White Syndrome and Adenosine ...

Do not use AV-nodal blocking agents for pre-excited atrial fibrillation. AV-nodal blockade may shift conduction preferentially to the accessory pathway and increase the risk of ventricular tachycardia or ventricular fibrillation. jacc+1jaccAtrial Fibrillation in Wolff-Parkinson-White Syndrome | JACC: Case ReportsPubMedProcainamide - StatPearls - NCBI Bookshelf

For hemodynamic instability during pre-excited atrial fibrillation, perform immediate electrical cardioversion rather than attempting AV-nodal blockade. The clinical priority is termination of the unstable rhythm before degeneration to ventricular fibrillation. jaccjaccAtrial Fibrillation in Wolff-Parkinson-White Syndrome | JACC: Case Reports

For hemodynamically stable pre-excited atrial fibrillation, intravenous procainamide or intravenous ibutilide are pharmacologic options. Ibutilide prolongs refractoriness in both the AV node and accessory pathway, whereas procainamide has relevant atrial myocardial effects and is used for acute termination in stable WPW-associated tachyarrhythmia. jacc+1jaccAtrial Fibrillation in Wolff-Parkinson-White Syndrome | JACC: Case ReportsPubMedProcainamide - StatPearls - NCBI Bookshelf

During acute procainamide treatment, use continuous cardiac monitoring, monitor blood pressure frequently, and stop infusion if QRS duration increases by 50% from baseline. Use caution in heart failure, hypokalemia, hypomagnesemia, hepatic impairment, renal impairment, myasthenia gravis, pregnancy, and breastfeeding when prolonged therapy is contemplated. PubMedPubMedProcainamide - StatPearls - NCBI Bookshelf

Refer patients with ventricular pre-excitation plus palpitations, syncope, documented supraventricular tachycardia, or atrial fibrillation to cardiac electrophysiology. Symptomatic pre-excitation establishes WPW syndrome, for which electrophysiologic study and catheter ablation of the accessory pathway are recommended approaches in guideline-based risk management. ScienceDirect+1ScienceDirectRisk Stratification for Arrhythmic Events in Patients With Asymptomatic Pre-Excitation: A Systematic Review for the 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm SocietyScienceDirect2015 ACC/AHA/HRS Guideline for the Management of ...

Prior pre-excited atrial fibrillation is a high-risk clinical feature because the accessory pathway has demonstrated antegrade conduction during atrial fibrillation. In this phenotype, the shortest pre-excited RR interval is the key ECG risk marker; a value below 250 ms predicts increased risk of ventricular fibrillation. jacc+1jaccAtrial Fibrillation in Wolff-Parkinson-White Syndrome | JACC: Case ReportsWileyWolff‐Parkinson‐White Syndrome and Adenosine ...

Catheter ablation is the definitive pathway-directed intervention after clinically significant pre-excitation or high-risk pathway assessment. In a longitudinal series of patients with antegrade accessory pathways, atrial fibrillation disappeared after loss of ventricular pre-excitation in 4 of 5 affected patients, supporting the accessory pathway as a modifiable arrhythmic substrate in selected patients. AHA JournalsAHA JournalsLongitudinal Clinical and Electrophysiological Assessment of Patients With Symptomatic Wolff-Parkinson-White Syndrome and Atrioventricular Node Reentrant Tachycardia

Distinguish asymptomatic ventricular pre-excitation from WPW syndrome by taking a targeted history for palpitations, exertional presyncope or syncope, documented atrial fibrillation, and prior emergency evaluations for tachycardia. Pre-excitation occurs in approximately 0.1% to 0.3% of the general population, while symptomatic pre-excitation carries a lifetime sudden cardiac death risk that may approach 4%. ScienceDirectScienceDirectRisk Stratification for Arrhythmic Events in Patients With Asymptomatic Pre-Excitation: A Systematic Review for the 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society

For truly asymptomatic patients, assess clinical risk modifiers: male sex, discovery in the first two decades of life, history of atrial fibrillation, arrhythmic symptoms—particularly syncope—congenital heart disease, familial WPW syndrome, high-risk occupation, and moderate- to high-intensity competitive sport. These features should lower the threshold for EP referral and discussion of prophylactic ablation. ACCACCAsymptomatic Ventricular Preexcitation (Wolff-Parkinson ...

Noninvasive or invasive testing is used to evaluate the rate of antegrade AV conduction over the accessory pathway. EP study may identify patients at high risk for future arrhythmic events, and accessory-pathway ablation should be considered when high-risk properties are found. ScienceDirect+1ScienceDirectRisk Stratification for Arrhythmic Events in Patients With Asymptomatic Pre-Excitation: A Systematic Review for the 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm SocietyACCAsymptomatic Ventricular Preexcitation (Wolff-Parkinson ...

At each follow-up, ask specifically about documented or suspected atrial fibrillation, rapid irregular palpitations, exertional syncope, and emergency presentations for tachycardia. A transition from asymptomatic ECG pre-excitation to symptoms consistent with SVT changes the diagnosis to WPW syndrome and strengthens the indication for EP evaluation. ScienceDirect+1ScienceDirectRisk Stratification for Arrhythmic Events in Patients With Asymptomatic Pre-Excitation: A Systematic Review for the 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm SocietyScienceDirect2015 ACC/AHA/HRS Guideline for the Management of ...

Review the baseline and post-event ECGs for persistent delta waves, PR interval shortening, and QRS morphology; subtle pre-excitation can be mistaken for bundle-branch block. Preserve ECGs that capture pre-excited atrial fibrillation because the shortest pre-excited RR interval directly informs ventricular-fibrillation risk assessment. jacc+1jaccAtrial Fibrillation in Wolff-Parkinson-White Syndrome | JACC: Case ReportsWileyWolff‐Parkinson‐White Syndrome Mimics a Conduction ...

After accessory-pathway ablation, clinical follow-up should focus on recurrent palpitations or atrial arrhythmia symptoms and on whether ventricular pre-excitation is absent on ECG. Loss of ventricular pre-excitation was associated with disappearance of atrial fibrillation in most affected patients in one longitudinal series, but recurrence symptoms still warrant rhythm documentation and EP reassessment. AHA JournalsAHA JournalsLongitudinal Clinical and Electrophysiological Assessment of Patients With Symptomatic Wolff-Parkinson-White Syndrome and Atrioventricular Node Reentrant Tachycardia