Wolff-Parkinson-White syndrome risk stratification: Difference between revisions

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{{Wolff-Parkinson-White syndrome}}
{{Wolff-Parkinson-White syndrome}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
{{CMG}}; {{AE}} {{Sara.Zand}} {{CZ}}


==Overview==
==Overview==
Treatment is based on risk stratification of the individual.  Risk stratification is performed to determine which individuals with WPW syndrome are at risk for sudden cardiac death (SCD). Sudden cardiac death in these individuals is due to the propagation of an atrial arrhythmia to the ventricles at a very high rate.
Treatment is based on the risk stratification of the individual.  Risk stratification is performed to determine which individuals with [[WPW syndrome]] are at risk for [[sudden cardiac death]] (SCD). [[Sudden cardiac death]] in these individuals is due to the propagation of an [[atrial arrhythmia]] to the [[ventricles]] at a very high rate. Noninvasive tests have a 70% [[positive predictive value]] and 30% [[negative predictive value]] for identifying [[pathways]] with [[life-threatening]] properties.[[ Electrophysiologic studies]] are useful for evaluation of patients' [[symptoms]].


A good history should be taken to determine whether an individual has factors suggestive of a previous episode of unexplained [[syncope]] (fainting) or[[palpitations]] (sudden awareness of one's own, usually irregular, heartbeat). These may be due to earlier episodes of a tachycardia associated with the accessory pathway.
==Risk Stratification==
:*Low-risk patients for life-threatening arrhythmia over the [[accessory pathway]] during [[AF]] include the following:<ref name="PageJoglar2016">{{cite journal|last1=Page|first1=Richard L.|last2=Joglar|first2=José A.|last3=Caldwell|first3=Mary A.|last4=Calkins|first4=Hugh|last5=Conti|first5=Jamie B.|last6=Deal|first6=Barbara J.|last7=Estes III|first7=N.A. Mark|last8=Field|first8=Michael E.|last9=Goldberger|first9=Zachary D.|last10=Hammill|first10=Stephen C.|last11=Indik|first11=Julia H.|last12=Lindsay|first12=Bruce D.|last13=Olshansky|first13=Brian|last14=Russo|first14=Andrea M.|last15=Shen|first15=Win-Kuang|last16=Tracy|first16=Cynthia M.|last17=Al-Khatib|first17=Sana M.|title=2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia|journal=Heart Rhythm|volume=13|issue=4|year=2016|pages=e136–e221|issn=15475271|doi=10.1016/j.hrthm.2015.09.019}}</ref>


Individuals with WPW syndrome in whom the delta waves disappear with increases in the heart rate are considered at lower risk of SCD.  This is because the loss of the delta wave shows that the accessory pathway cannot conduct electrical impulses at a high rate (in the anterograde direction).  These individuals will typically not have fast conduction down the accessory pathway during episodes of atrial fibrillation.
*Abrupt loss of conduction over the pathway during [[ exercise test]] in [[sinus rhythm]]
*Intermittent loss of preexcitation during [[EKG]] or [[ambulatory monitoring]]


Risk stratification is best performed via [[programmed electrical stimulation]] (PES) in the [[cardiac electrophysiology]] lab.  This is an invasive procedure, in which the rate of impulse propagation via the accessory pathway is determined by stimulating the atria and by inducing transient [[atrial fibrillation]].
:*High-risk patients for life-threatening arrhythmia in the [[electrophysiologic study]] include the following:


High risk features that may be present during PES include an effective refractory period of the accessory pathway less than 270 ms, multiple pathways, septal location of pathway, and inducibility of supraventricular tachycardia.  Individuals with any of these high risk features are generally considered at increased risk for SCD and should be treated accordingly.<ref name = Pappone_et_al_2003>{{cite journal
* [[R-R interval]]<250 ms between two pre-excited complexes during induced [[ AF]]
| author=Pappone C, Santinelli V, Manguso F, Augello G, Santinelli O, Vicedomini G, Gulletta S, Mazzone P, Tortoriello V, Pappone A, Dicandia C, Rosanio S.
* The presence of multiple [[accessory pathways]]
| title=A randomized study of prophylactic catheter ablation in asymptomatic patients with the Wolff-Parkinson-White syndrome
* The finding of [[AVRT]] precipitating pre-excited [[AF]]
| journal=New England Journal of Medicine
* [[Accessory pathway]] refractory period<240 ms
| volume=349
| issue=19
| year=2003
| pages=1803-11
| id=PMID 14602878
| url = http://content.nejm.org/cgi/content/full/349/19/1803
| format = free registration required }}</ref>
 
It is unclear whether invasive risk stratification (with programmed electrical stimulation) is necessary in the asymptomatic individual.<ref name =Cambell_et_al_2003>{{cite journal
| author=Campbell RM, Strieper MJ, Frias PA, Collins KK, Van Hare GF, Dubin AM
| title=Survey of current practice of pediatric electrophysiologists for asymptomatic Wolff-Parkinson-White syndrome
| journal=Pediatrics
| volume=111| issue=3| year=2003| pages=e245-7
| id=PMID 12612279
| url = http://pediatrics.aappublications.org/cgi/content/full/111/3/e245
}}</ref>  While some groups advocate PES for risk stratification in all individuals under 35 years old, others only offer it to individuals who have history suggestive of a [[tachycardia|tachyarrhythmia]], since the incidence of sudden death is so low.
----
Shown below is an EKG demonstrating  WPW syndrome. The accessory pathway is located in the left posteroseptal region.
 
[[Image:Wolff-Parkinson-White_syndrome_12_lead_EKG.png|center|500px]]
 
<br clear="left"/>


==References==
==References==
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[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Disease]]
   
   
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Latest revision as of 10:38, 15 September 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]

Overview

Treatment is based on the risk stratification of the individual. Risk stratification is performed to determine which individuals with WPW syndrome are at risk for sudden cardiac death (SCD). Sudden cardiac death in these individuals is due to the propagation of an atrial arrhythmia to the ventricles at a very high rate. Noninvasive tests have a 70% positive predictive value and 30% negative predictive value for identifying pathways with life-threatening properties.Electrophysiologic studies are useful for evaluation of patients' symptoms.

Risk Stratification

  • Low-risk patients for life-threatening arrhythmia over the accessory pathway during AF include the following:[1]

References

  1. Page, Richard L.; Joglar, José A.; Caldwell, Mary A.; Calkins, Hugh; Conti, Jamie B.; Deal, Barbara J.; Estes III, N.A. Mark; Field, Michael E.; Goldberger, Zachary D.; Hammill, Stephen C.; Indik, Julia H.; Lindsay, Bruce D.; Olshansky, Brian; Russo, Andrea M.; Shen, Win-Kuang; Tracy, Cynthia M.; Al-Khatib, Sana M. (2016). "2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia". Heart Rhythm. 13 (4): e136–e221. doi:10.1016/j.hrthm.2015.09.019. ISSN 1547-5271.

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