Wolff–Parkinson–White syndrome: Difference between revisions
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**Delta wave and QRS complex predominantly negative in V! and V2 | **Delta wave and QRS complex predominantly negative in V! and V2 | ||
**Delta wave and QRS complex predominantly positive in other precordial leads <ref>https://patient.info/doctor/wolff-parkinson-white-syndrome-pro</ref> | **Delta wave and QRS complex predominantly positive in other precordial leads <ref>https://patient.info/doctor/wolff-parkinson-white-syndrome-pro</ref> | ||
*Appearance of left bundle branch block <ref>https://emedicine.medscape.com/article/159222-workup#c8</ref> | **Appearance of left bundle branch block <ref>https://emedicine.medscape.com/article/159222-workup#c8</ref> | ||
=== | ===Types by Cycle Direction=== | ||
*Most common variant (~95% of cases) | *Orthodromic | ||
* | **Accessory pathway with ''retrograde'' reentry conduction | ||
*QRS narrow (delta wave absent) | **Most common variant (~95% of cases) | ||
**Referred to as 'concealed' accessory pathway <ref>https://emedicine.medscape.com/article/159222-workup#c8</ref> | **QRS narrow (delta wave absent) | ||
*May see ST depression, TWI | ***Referred to as 'concealed' accessory pathway <ref>https://emedicine.medscape.com/article/159222-workup#c8</ref> | ||
*Rate 150-250 bpm | **May see ST depression, TWI | ||
**Rate 150-250 bpm | |||
*Antidromic | |||
*Least common variant (~5% of cases) | **Accessory pathway with ''anterograde'' reentry conduction | ||
* | **Least common variant (~5% of cases) | ||
*QRS wide, delta wave present | **QRS wide, delta wave present | ||
*Rate 160-220 bpm, regular | **Rate 160-220 bpm, regular | ||
===Atrial Fibrillation and Flutter<ref>Burns E. Wolff-Parkinson-White Syndromes. Life in the Fast Lane. http://lifeinthefastlane.com/ecg-library/pre-excitation-syndromes/.</ref>=== | ===Atrial Fibrillation and Flutter<ref>Burns E. Wolff-Parkinson-White Syndromes. Life in the Fast Lane. http://lifeinthefastlane.com/ecg-library/pre-excitation-syndromes/.</ref>=== | ||
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''Treat like paroxysmal SVT'' | ''Treat like paroxysmal SVT'' | ||
*Unstable | *Unstable | ||
**Cardioversion (synchronized) | **[[Cardioversion]] (synchronized) | ||
**Adult: 50-100 J | **Adult: 50-100 J | ||
**Peds: 0.5-2 J/kg | **Peds: 0.5-2 J/kg | ||
*Stable | *Stable | ||
**Calcium channel blockers, beta-blockers, procainamide, or adenosine | **[[Calcium channel blockers]], [[beta-blockers]], [[procainamide]], or [[adenosine]] | ||
**Procainamide safe irrespective of type of pathway conduction | **[[Procainamide]] is safest, as safe irrespective of type of pathway conduction | ||
===Antidromic=== | ===Antidromic=== | ||
''Treat like ventricular tachycardia'' | ''Treat like [[ventricular tachycardia]]'' | ||
*Synchronized cardioversion | *Synchronized [[cardioversion]] | ||
**Adult: 50-100 J | **Adult: 50-100 J | ||
**Peds: 0.5-2 J/kg | **Peds: 0.5-2 J/kg | ||
**Procainamide | **[[Procainamide]] (see page for dosing guidelines) | ||
***Avoid if prolong QT or CHF | ***Avoid if prolong QT or CHF | ||
**Amiodarone with 'ABCD' drugs ie adenosine, beta-blockers, calcium-channel blockers, digoxin | **[[Amiodarone]] with 'ABCD' drugs ie [[adenosine]], [[beta-blockers]], [[calcium-channel blockers]], [[digoxin]] | ||
*Wide-complex, irregular (presumed preexcited A-fib) | *Wide-complex, irregular (presumed preexcited [[A-fib]]) | ||
**Unsynchronized cardioversion (200J) | **Unsynchronized cardioversion (200J) | ||
===Atrial Fibrillation and Atrial Flutter=== | ===[[Atrial Fibrillation]] and [[Atrial Flutter]]=== | ||
*Stable | *Stable | ||
**Procainamide 20-50 mg/min until arrhythmia suppressed | **[[Procainamide]] 20-50 mg/min until arrhythmia suppressed | ||
**Synchronized cardioversion, 100 - 200 J | **Synchronized [[cardioversion]], 100 - 200 J | ||
*Unstable - synchronized cardioversion | *Unstable - synchronized cardioversion | ||
**Consider higher joule dosage and frequency of repeats than for stable | **Consider higher joule dosage and frequency of repeats than for stable | ||
*Avoid AV nodal blocking agents | *'''Avoid''' AV nodal blocking agents | ||
==Disposition== | ==Disposition== |
Revision as of 03:40, 28 November 2019
Background
- Abbreviation: WPW
- Congenital pre-excitation syndrome
- Presence of an accessory electrical pathway between atria and ventricles predisposing to supraventricular tachycardia
- Associated with certain genetic predispositions, Ebstein anomaly, and hypokalemic periodic paralysis[1] [2]
Types by Aberrant Pathway Site
- Type A
- Type B
Types by Cycle Direction
- Orthodromic
- Accessory pathway with retrograde reentry conduction
- Most common variant (~95% of cases)
- QRS narrow (delta wave absent)
- Referred to as 'concealed' accessory pathway [7]
- May see ST depression, TWI
- Rate 150-250 bpm
- Antidromic
- Accessory pathway with anterograde reentry conduction
- Least common variant (~5% of cases)
- QRS wide, delta wave present
- Rate 160-220 bpm, regular
Atrial Fibrillation and Flutter[8]
- Atrial fibrillation in up to 20% of patients with WPW
- Irregular rhythm, wide QRS complexes
- Changing QRS complexes in shape and morphology
- Axis remains stable as opposed to polymorphic VT
- Atrial flutter in ~7% of patients with WPW
- Similar features to atrial fibrillation with WPW
- Except regular rhythm
- Easily mistaken for monomorphic ventricular tachycardia
- Note that if unclear, always safest to assume VT and treat with shock
- Treatment with AV nodal blocking agents (adenosine, beta-blockers, calcium-channel blockers, amiodarone, digoxin) may incite ventricular fibrillation or ventricular tachycardia
- "Manifest WPW" = degeneration into VT or VF
Clinical Features
- Suspect in any patient with ventricular rate >300
- Many are asymptomatic
Infants
- Irritability, feeding intolerance
- CHF
- Intercurrent febrile illness
Children
- Chest pain, palpitations
- Shortness of breath
- Syncope/near-syncope
Adults
- Sudden onset "racing heart"
Differential Diagnosis
Narrow-complex tachycardia
- Regular
- AV Node Independent
- Sinus tachycardia
- Atrial tachycardia (uni-focal or multi-focal)
- Atrial fibrillation
- Atrial flutter
- Idiopathic fascicular left ventricular tachycardia
- AV Node Dependent
- AV Node Independent
- Irregular
- Multifocal atrial tachycardia (MAT)
- Sinus tachycardia with frequent PACs, PJCs, PVCs
- Atrial fibrillation
- Atrial flutter with variable conduction
- Digoxin Toxicity
Wide-complex tachycardia
Assume any wide-complex tachycardia is ventricular tachycardia until proven otherwise (it is safer to incorrectly assume a ventricular dysrhythmia than supraventricular tachycardia with abberancy)
- Regular
- Monomorphic ventricular tachycardia
- PSVT with aberrant conduction:
- PSVT with bundle branch block^
- PSVT with accessory pathway
- Atrial flutter with bundle branch block^
- Sinus tachycardia with bundle branch block^
- Accelerated idioventricular rhythm (consider if less than or ~120 bpm)
- Metabolic
- Irregular
- Atrial fibrillation/atrial flutter with variable AV conduction AND bundle branch block^
- Atrial fibrillation/atrial flutter with variable AV conduction AND accessory pathway (e.g. WPW)
- Atrial fibrillation + hyperkalemia
- Polymorphic ventricular tachycardia
^Fixed or rate-related
Palpitations
- Arrhythmias:
- Non-arrhythmic cardiac causes:
- Psychiatric causes:
- Drugs and Medications:
- Alcohol
- Caffeine
- Drugs of abuse (e.g. cocaine)
- Medications (e.g. digoxin, theophylline)
- Tobacco
- Misc
Evaluation
Workup
Diagnosis
Although the ECG and an electrophysiology study are diagnostic, the characteristic features are not always seen on ECG
- Short PR interval - <0.12sec
- Due to loss of normal AV node conduction delay
- Differentiate from premature junctional complex
- Delta wave / slurred upstroke
- Due to early activation of ventricular myocardium
- QRS duration > 0.10 sec
- Represents a fusion beat
- Dominant R wave in V1, Type A WPW
- Left sided accessory pathway
- Dominant S wave in V1, Type B WPW
- Right sided accessory pathway
- Tall R waves in V1-V3 with T wave inversion
- Mimic RVH
- "Negative" delta waves in III and aVF
- Appear as pseudo-infarct Q waves
- Mimics prior inferior infarct
Management
Orthodromic
Treat like paroxysmal SVT
- Unstable
- Cardioversion (synchronized)
- Adult: 50-100 J
- Peds: 0.5-2 J/kg
- Stable
- Calcium channel blockers, beta-blockers, procainamide, or adenosine
- Procainamide is safest, as safe irrespective of type of pathway conduction
Antidromic
Treat like ventricular tachycardia
- Synchronized cardioversion
- Adult: 50-100 J
- Peds: 0.5-2 J/kg
- Procainamide (see page for dosing guidelines)
- Avoid if prolong QT or CHF
- Amiodarone with 'ABCD' drugs ie adenosine, beta-blockers, calcium-channel blockers, digoxin
- Wide-complex, irregular (presumed preexcited A-fib)
- Unsynchronized cardioversion (200J)
Atrial Fibrillation and Atrial Flutter
- Stable
- Procainamide 20-50 mg/min until arrhythmia suppressed
- Synchronized cardioversion, 100 - 200 J
- Unstable - synchronized cardioversion
- Consider higher joule dosage and frequency of repeats than for stable
- Avoid AV nodal blocking agents
Disposition
Discharge
- Consider if dysrhythmia was easily terminated and can arrange outpatient EP study with possible RF catheter ablation
- Consider consulting cardiologist regarding outpatient beta-blockers vs. more potent medications (amiodarone, sotalol, flecainide, etc.)
Admit[9]
- Patients with chest pain, CHF, electrolyte imbalance, or required cardioversion
- Syncope
- Uncertain diagnosis (wide-complex tachycardia)
- Significant associated structural heart disease (MVP, cardiomyopathy)
- Family history of Sudden cardiac death
- Atrial flutter or atrial fibrillation
See Also
- Paroxysmal supraventricular tachycardia
- Atrial fibrillation (main)
- Atrial fibrillation with RVR
- Tachycardia (narrow)
- Tachycardia (wide)
External Links
References
- ↑ https://rarediseases.org/rare-diseases/wolff-parkinson-white-syndrome/
- ↑ https://patient.info/doctor/wolff-parkinson-white-syndrome-pro
- ↑ https://patient.info/doctor/wolff-parkinson-white-syndrome-pro
- ↑ https://emedicine.medscape.com/article/159222-workup#c8
- ↑ https://patient.info/doctor/wolff-parkinson-white-syndrome-pro
- ↑ https://emedicine.medscape.com/article/159222-workup#c8
- ↑ https://emedicine.medscape.com/article/159222-workup#c8
- ↑ Burns E. Wolff-Parkinson-White Syndromes. Life in the Fast Lane. http://lifeinthefastlane.com/ecg-library/pre-excitation-syndromes/.
- ↑ Ellis CR et al. Wolff-Parkinson-White Syndrome Treatment & Management. eMedicine. Dec 4, 2015. http://emedicine.medscape.com/article/159222-treatment#showall.