Wolff–Parkinson–White syndrome: Difference between revisions

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==Background==
==Background==
*Suspect in any pt w/ ventricular rate >300
[[File:WPW.jpeg|thumb|Graphic representation of the bundle of Kent in Wolff–Parkinson–White syndrome]]
*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]]<ref>https://rarediseases.org/rare-diseases/wolff-parkinson-white-syndrome/</ref> <ref>https://patient.info/doctor/wolff-parkinson-white-syndrome-pro</ref>


===Orthodromic Type===
===Types by Aberrant Pathway Site===
*More common type occuring ~95% of the time
*Type A
*Accessory pathway (Kent bundles) is used for retrograde reentry conduction
**Pathway between the ''left'' atrium and ventricle
*QRS narrow (delta wave absent)
**Delta wave and QRS complex predominantly upright in precordial leads <ref>https://patient.info/doctor/wolff-parkinson-white-syndrome-pro</ref>
*May see ST depression, TWI
**Dominant R wave (greater than S amplitude) in V1 may have appearance of right bundle branch block <ref>https://emedicine.medscape.com/article/159222-workup#c8</ref>
*Rate 150-250 bpm
*Type B
===Antidromic Type===
**Pathway between the ''right'' atrium and ventricle
*Least common type occuring ~5% of the time
**Delta wave and QRS complex predominantly negative in V1 and V2
*Accessory pathway used for anterograde conduction
**Delta wave and QRS complex predominantly positive in other precordial leads <ref>https://patient.info/doctor/wolff-parkinson-white-syndrome-pro</ref>
*QRS wide, delta wave present
**Appearance of left bundle branch block <ref>https://emedicine.medscape.com/article/159222-workup#c8</ref>
 
===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 <ref>https://emedicine.medscape.com/article/159222-workup#c8</ref>
**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<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>===
*[[Atrial fibrillation]] in up to 20% of pts with WPW
*[[Atrial fibrillation]] in up to 20% of patients with WPW
*[[Atrial flutter]] in ~7%  
**Irregular rhythm, wide QRS complexes
*Treatment with AV nodal blocking agents (adenosine, BBs, CCBs, amiodarone) may incite [[ventricular fibrillation]] or [[ventricular tachycardia]]
**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==
{{Tachycardia (narrow) DDX}}
{{Tachycardia (wide) DDX}}
{{Palpitations DDX}}
 
==Evaluation==
===Workup===
[[File:DeltaWave09.jpg|thumb|Delta wave]]
*[[ECG]]


==Diagnosis==
===Diagnosis===
[[File:WPW09.jpg|thumb|12 lead electrocardiogram showing classic findings]]
''Although the ECG and an electrophysiology study are diagnostic, the characteristic features are not always seen on ECG''
''Although the ECG and an electrophysiology study are diagnostic, the characteristic features are not always seen on ECG''
#Short PR interval - <0.12sec
*Short PR interval - <0.12sec
##Due to loss of normal AV node conduction delay
**Due to loss of normal AV node conduction delay
##Differentiate from [[premature junctional complex]]
**Differentiate from [[premature junctional complex]]
#Delta wave / slurred upstroke
*Delta wave / slurred upstroke
##Due to early activation of ventricular myocardium
**Due to early activation of ventricular myocardium
#QRS duration > 0.10 sec
*QRS duration > 0.10 sec
##Represents a fusion beat
**Represents a fusion beat
#Dominant R wave in V1, Type A WPW
*Dominant R wave in V1, Type A WPW
##Left sided accessory pathway
**Left sided accessory pathway
#Dominant S wave in V1, Type B WPW
*Dominant S wave in V1, Type B WPW
##Right sided accessory pathway
**Right sided accessory pathway
#Tall R waves in V1-V3 with [[T wave]] inversion
*Tall R waves in V1-V3 with [[T wave]] inversion
##Mimic RVH
**Mimic RVH
#"Negative" delta waves in III and aVF
*"Negative" delta waves in III and aVF
##Appear as pseudo-infarct Q waves
**Appear as pseudo-infarct Q waves
##Mimics prior inferior infarct
**Mimics prior inferior infarct


==Treatment==
==Management==
===Orthodromic===
===Orthodromic===
''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
**CCBs, BBs, 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: 17mg/kg IV over 30min (up to 50mg/kg or 50% widening of QRS complex)
**[[Procainamide]] (see page for dosing guidelines)
**Amiodarone with 'ABCD' drugs ie adenosine, BBs, CCBs, digoxin
***Avoid if prolong QT or CHF
*Wide-complex, irregular (presumed preexcited A-fib)
**[[Amiodarone]] with 'ABCD' drugs ie [[adenosine]], [[beta-blockers]], [[calcium-channel blockers]], [[digoxin]]
*Wide-complex, irregular (presumed preexcited [[A-fib]])
**Unsynchronized cardioversion (200J)
**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==
==Disposition==
*Discharge:
===Discharge===
**Consider if dysrhythmia was easily terminated and can arrange outpt EP study with poss RF catheter ablation
*Consider if dysrhythmia was easily terminated and can arrange outpatient EP study with possible RF catheter ablation
**C/w with cardiologist regarding outpt beta-blockers vs. more potent medications (amiodarone, sotalol, flecainide, etc.)
*Consider consulting cardiologist regarding outpatient [[beta-blockers]] vs. more potent medications ([[amiodarone]], [[sotalol]], [[flecainide]], etc.)
*Admit or transfer to center with electrophys<ref>Ellis CR et al. Wolff-Parkinson-White Syndrome Treatment & Management. eMedicine. Dec 4, 2015. http://emedicine.medscape.com/article/159222-treatment#showall.</ref>:
 
**Pts with chest pain, CHF, electrolyte imbalance, or required cardioversion
===Admit<ref>Ellis CR et al. Wolff-Parkinson-White Syndrome Treatment & Management. eMedicine. Dec 4, 2015. http://emedicine.medscape.com/article/159222-treatment#showall.</ref>===
**Syncope
*Patients with [[chest pain]], [[CHF]], [[electrolyte imbalance]], or required [[cardioversion]]
**Uncertain dx (wide-complex tachycardia)
*[[Syncope]]
**Significant associated structural heart disease (MVP, cardiomyopathy)
*Uncertain diagnosis (wide-complex tachycardia)
**Family hx of [[Sudden cardiac death]]
*Significant associated structural heart disease (MVP, cardiomyopathy)
**[[Atrial flutter]] or [[atrial fibrillation]]
*Family history of [[Sudden cardiac death]]
*[[Atrial flutter]] or [[atrial fibrillation]]


==See Also==
==See Also==
*[[SVT]]
*[[Paroxysmal supraventricular tachycardia]]
*[[Atrial fibrillation (main)]]
*[[Atrial fibrillation with RVR]]
*[[Tachycardia (narrow)]]
*[[Tachycardia (wide)]]
 
==External Links==
[https://www.youtube.com/watch?time_continue=38&v=qrhWH2_KKOY WPW with AFIB]


==Sources==
==References==
*Burns E. Pre-excitation Syndromes. Life in the Fast Lane. http://lifeinthefastlane.com/ecg-library/pre-excitation-syndromes/.
<references/>  
<references/>  


[[Category:Cardiology]]
[[Category:Cardiology]]

Latest revision as of 18:03, 28 March 2022

Background

Graphic representation of the bundle of Kent in Wolff–Parkinson–White syndrome
  • 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
    • Pathway between the left atrium and ventricle
    • Delta wave and QRS complex predominantly upright in precordial leads [3]
    • Dominant R wave (greater than S amplitude) in V1 may have appearance of right bundle branch block [4]
  • Type B
    • Pathway between the right atrium and ventricle
    • Delta wave and QRS complex predominantly negative in V1 and V2
    • Delta wave and QRS complex predominantly positive in other precordial leads [5]
    • Appearance of left bundle branch block [6]

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

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)

^Fixed or rate-related

Palpitations

Evaluation

Workup

Delta wave

Diagnosis

12 lead electrocardiogram showing classic findings

Although the ECG and an electrophysiology study are diagnostic, the characteristic features are not always seen on ECG

  • Short PR interval - <0.12sec
  • 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

Antidromic

Treat like ventricular tachycardia

Atrial Fibrillation and Atrial Flutter

  • Stable
  • 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]

See Also

External Links

WPW with AFIB

References