Wolff–Parkinson–White syndrome: Difference between revisions
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==Background== | ==Background== | ||
* | [[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> | |||
=== | ===Types by Aberrant Pathway Site=== | ||
* | *Type A | ||
*Accessory pathway | **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 | ||
**Pathway between the ''right'' atrium and ventricle | |||
*Least common | **Delta wave and QRS complex predominantly negative in V1 and V2 | ||
* | **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 | *[[Atrial fibrillation]] in up to 20% of patients with WPW | ||
**Irregular | **Irregular rhythm, wide QRS complexes | ||
**Changing QRS complexes in shape and morphology | **Changing QRS complexes in shape and morphology | ||
**Axis remains stable as opposed to polymorphic VT | **Axis remains stable as opposed to polymorphic VT | ||
*[[Atrial flutter]] in ~7% of | *[[Atrial flutter]] in ~7% of patients with WPW | ||
**Similar features to atrial fibrillation with WPW | **Similar features to atrial fibrillation with WPW | ||
**Except regular | **Except regular rhythm | ||
**Easily mistaken for | **Easily mistaken for monomorphic ventricular tachycardia | ||
*Treatment with AV nodal blocking agents (adenosine, | **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 | *"Manifest WPW" = degeneration into VT or VF | ||
==Diagnosis== | ==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=== | |||
[[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 | |||
**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=== | ===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 | ||
** | **[[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) | ||
**Amiodarone with 'ABCD' drugs ie adenosine, | ***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=== | ===[[Atrial Fibrillation]] and [[Atrial Flutter]]=== | ||
*Stable - synchronized cardioversion | *Stable | ||
* | **[[Procainamide]] 20-50 mg/min until arrhythmia suppressed | ||
*Avoid AV nodal blocking agents | **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=== | |||
*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<ref>Ellis CR et al. Wolff-Parkinson-White Syndrome Treatment & Management. eMedicine. Dec 4, 2015. http://emedicine.medscape.com/article/159222-treatment#showall.</ref>=== | ||
* | *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== | ==See Also== | ||
*[[ | *[[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] | [https://www.youtube.com/watch?time_continue=38&v=qrhWH2_KKOY WPW with AFIB] | ||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:Cardiology]] | [[Category:Cardiology]] |
Latest revision as of 18:03, 28 March 2022
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.