Wolff-Parkinson-White syndrome medical therapy: Difference between revisions

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{{Wolff-Parkinson-White syndrome}}
{{Wolff-Parkinson-White syndrome}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{Sara.Zand}} {{CZ}}; {{Rim}}
 
==Overview==
==Overview==
Acutely, people with WPW who are experiencing a tachydysrhythmia may require electrical [[cardioversion]] if their condition is critical, or, if more stable, medical treatment may be used.  Patients with atrial fibrillation and rapid ventricular response are often treated with [[amiodarone]] or[[procainamide]] to stabilize their heart rate. Adenosine and other AV node blockers should be avoided in Atrial fibriliiatin with WPW; this inlcudes adenosine, diltiazem, verapamil,other calcium channel blockers and Beta-blockers.  Patients with a rapid heart beat with narrow [[QRS complex]]es (circus movement tachycardias) may also be cardioverted, alternatively, [[adenosine]] may be administered if equipment for cardioversion is immediately available as a backup.


The definitive treatment of WPW syndrome is a destruction of the abnormal electrical pathway by radiofrequency [[catheter ablation]].  This procedure is performed almost exclusively by [[cardiac electrophysiology|cardiac electrophysiologists]]. Radiofrequency catheter ablation is not performed in all individuals with WPW syndrome because there are inherent risks involved in the procedure.
[[Wolff-Parkinson-White syndrome]] patients who are hemodynamically unstable, as reflected by the presence of [[hypotension]], [[cold extremities]], [[mottling]] or [[peripheral cyanosis]], or those who present with ischemic [[chest pain]] or decompensated [[heart failure]] should urgently undergo direct current cardioversion. The medical therapy of hemodynamically stable patients with [[WPW]] syndrome depends on the type of the [[tachycardia]].  When the [[ECG]] findings suggest orthodromic [[AVRT]], the patient should be managed similarly to patients with [[SVT|supreventricular tachycardia]] followed by the sequential administration of [[adenosine]], [[verapamil]] and [[procainamide]] in case of failure to improveAmong patients with antidromic [[AVRT]], [[AV node|AV nodal]] blocking agents should be avoided and patients should be treated with either [[procainamide]], [[ibutilide]] or [[flecainide]]. The long term treatment of patients with [[WPW]] syndrome depends on the presence or absence of [[symptoms]] and their severity.  Patients who have poorly tolerated symptomatic [[WPW syndrome]] should undergo [[catheter ablation.
Adeosine is contraindicated for patients in atrial fibrillation or atrial flutter with a history of WPW
 
==Acute Treatment==
===Atrioventricular Reentrant Tachycardia (AVRT)===
* [[AVRT]] is one of the type of [[tachycardia]] that can occur in patients with [[WPW]] pattern. 
*[[ AVRT]] can be either orthodromic or antidromic and the treatment of them is different.
====Hemodynamically Unstable Patients====
:* [[WPW]] syndrome patients with [[AVRT]] who are hemodynamically unstable,should urgently undergo [[direct current cardioversion]]
:* The signs of instability of hemodynamic include the following:
* [[hypotension]],
* [[cold extremities]]
* [[mottling]]
* [[peripheral cyanosis]]
* [[chest pain]]
* decompensated [[heart failure]]
** The shocks should be delivered as follows:
** Narrow regular rhythm: synchronized electrical cardioversion, 50-100 Joules
** Narrow irregular rhythm: synchronized electrical cardioversion, 120-200 Joules biphasic or 200 Joules monophasic
** Wide regular rhythm: synchronized electrical cardioversion, 100 Joules
** Wide irregular rhythm: unsynchronized electrical cardioversion, 200-360 Joules monophasic, or 100-200 Joules biphasic<ref name="ACLS">{{Cite web  | last =  | first =  | title = Part 8: Adult Advanced Cardiovascular Life Support | url = http://circ.ahajournals.org/content/122/18_suppl_3/S729.full | publisher =  | date =  | accessdate = 3 April 2014 }}</ref>
 
====Orthodromic [[AVRT]] in Hemodynamically Stable Patients====
* The management of [[WPW syndrome]] patients who are hemodynamically stable depends on the type of [[AVRT]].
* When the [[ECG]] findings suggest orthodromic [[AVRT]] and [[QRS]] complex is narrow, the patient should be managed similarly to patients with [[SVT|supreventricular tachycardia]].
* The management should begin with [[vagal maneuvers]] such as [[carotid sinus massage]] and [[valsalva maneuver]].
* If the patient's tachycardia does not resolve, the patient should be administered IV [[adenosine]].  
* In case of failure to improve, administration of [[ibutilide ]] may be considered followed by [[procainamide]]
 
The sequence of therapeutic decisions is summarized below.<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>
 
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for acute treatment of orthodromic AVRT'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Vagal maneuver ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Carotid sinus massage]] for 5-10 seconds in the absence of bruit <br>
❑ [[Valsalva maneuver]] for 10-30 seconds by bearing down against closed glottis, a more successful technique<br>
❑ Applying ice-cold wet towel to the face<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Adenosin([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Effective in conversion of [[AVRT]] in 90-95% patients <br>
❑ Episode of [[AVRT]] may be induced  again by [[ PAC]] or [[PVC]] after termination of [[tachyarrhythmia]] by [[adenosin]] <br>
❑ [[AF]] may be induced by [[adenosin]], rapidly passing through [[accessory pathway]]
<span style="font-size:85%;color:red">[[Contraindication|<span style="color:red">Contraindications:</span>]] [[asthma|<span style="color:red">asthma,</span>]] [[Second degree AV block|<span style="color:red">second degree AV block</span>]] or [[Third degree AV block|<span style="color:red">third degree AV block</span>]]  unless a [[Artificial pacemaker|<span style="color:red">pacemaker</span>]] is present</span>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Synchronized cardioversion]] : ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|❑ Highly effective in termination of AVRT<br>
❑ In [[unstable hemodynamic]] or stable hemodynamic and ineffectiveness of [[vagal maneuver]] or adenosine is recommended<br>
❑ Avoidance of complications associated [[antiarrhythmic]] drugs <br>
❑ In the presence of [[PVC]] or [[PAC]]  just after [[cardioversion]], [[antiarrhythmic]] drugs is recommended for prevention of restarting [[AVRT]] <br>
❑ In the  presence of hemodynamically  unstable and pre excited [[AF]], [[synchronized cardioversion]] is recommended
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Ibutilide]] or intravenous [[procainamide]]:([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ effective in hemodynamic stable and preexcited [[AF]] by slowing conduction over the [[accessory pathway]]<br>
<span style="font-size:85%;color:red"> [[Contraindication|<span style="color:red">Contraindications:</span>]] [[Compromised left ventricular function|<span style="color:red">Compromised left ventricular function</span>]]
<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Intravenous diltiazem,verapamil ,beta blockers]] : ([[ACC AHA guidelines classification scheme|Class 2a, Level of Evidence B-C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Effective for acute treatment of orthodromic [[AVRT]] without pre-excitation on resting [[ECG]] during [[sinus rhythm]](LOR=B)<br>
❑ Intravenous [[ diltiazem]] or [[verapamil]]  effectively terminate  90% to 95% of [[AVRT]] without [[pre-excitation]] on their resting [[sinus-rhythm]] [[ECG]]<br>
❑ Hypotension may occur in 3% patients receiving Intravenous [[diltiazem]] or [[verapamil]] <br>
❑ Intravenous [[beta blocker]] are effective for terminating [[AVRT]] with low risk of associated complications(LOR=C)<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Intravenous [[betablockers]],[[diltiazem]],[[verapamil]] ([[ACC AHA guidelines classification scheme|Class 2b, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Acute termination of orthodromic [[AVRT]] with [[pre-excitation]] on resting [[ECG]] without response to other treatment<br>
❑ The complication is enhancing conduction over the [[accessory pathway]] if the [[AVRT]] converts to [[ AF]] during the administration of the medication<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intravenous [[digoxin]],intravenous [[amiodarone]],intravenous or oral [[beta blockers]],[[diltiazem]],[[verapamil]] : ([[ACC AHA guidelines classification scheme|Class 3, Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Harmful in acute termination of peexcitated [[AF]]  due to increased risk of [[ventricular fibrillation]] by these mechanisms: <br>
❑ Increased conduction over the [[accessory pathway]] and slowing or blocking conduction over [[AV node]] <br>
❑ Deceased [[refractory period]] of [[accessory pathway]] by [[digoxin]]<br>
❑ Increased cathecolamin due to drug induced [[hypotension]] such as  [[amiodarone]], [[beta blocker]], [[verapamil]], [[diltiazem]]<br>
|}
 
====Antidromic AVRT in Hemodynamically Stable Patients====
* In antidromic AVRT, the antegrade conduction of the electrical signals occurs through the [[accessory pathway]], while the retrograde conduction occurs through either the [[AV node]] or a second [[accessory pathway]].<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>
*  In antidromic [[AVRT]], [[AV node|AV nodal]] blocking agents should be avoided.
*  [[Digoxin]], [[calcium channel blockers]], [[beta blockers]] and [[adenosine]] should be avoided.
*  [[Adenosine]] may lead to [[atrial fibrillation]] with rapid ventricular response. 
*  [[Procainamide]] or [[ibutilide]] are recommended  .
 
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center colspan=3|'''Treatment of Antidromic AVRT in Hemodynamically Stable Patients'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Medication''' || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left| '''Dosage''' || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Notes'''
|-
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=left | [[Procainamide]]
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=left | 100 mg infusion diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=left | ❑ Give until the [[arrhythmia]] is suppressed or until 500 mg has been administered <br>
❑ Wait 10 minutes or longer to administer new dosage<br>
<span style="font-size:85%;color:red">[[Contraindication|<span style="color:red">Contraindications:</span>]] [[Third degree AV block|<span style="color:red">third degree AV block</span>]], [[Systemic lupus erythematosus|<span style="color:red">lupus erythematosus</span>]], [[Hypersensitivity|<span style="color:red">idiosyncratic hypersensitivity</span>]], [[Torsades de pointes|<span style="color:red">torsades de pointes</span>]]</span>
|-
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=left |[[Ibutilide]]
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=left |1 mg IV infusion over 10 minutes
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=left |❑ Repeat the dosage if the [[tachycardia]] continues <br>
<span style="font-size:85%;color:red">[[Contraindication|<span style="color:red">Contraindications:</span>]] [[Hypersensitivity|<span style="color:red">hypersensitivity</span>]] to [[Ibutilide|<span style="color:red">ibutilide</span>]] or any component of the formulation, [[QT interval|<span style="color:red">QTc</span>]] >440 msec</span>
|}
 
===Atrial Fibrillation===
* WPW syndrome with [[atrial fibrillation]] should be suspected whenever the [[ECG]] reveals an irregular rhythm with absent [[P wave]] in the presence of a [[heart rate]] more than 240 beats per minute.


When performed by an experienced electrophysiologist, radiofrequency ablation has a high success rate.<ref name = Pappone_et_al_1993>{{cite journal
====Hemodynamically Unstable Patients====
  | author=Pappone C, Lamberti F, Santomauro M, Stabile G, De Simone A, Turco P, Pannain S, Loricchio ML, Rotunno R, Chiariello M
In hemodynamically unstable patients, urgent [[direct current cardioversion]] should be performed.<ref name="ACLS">{{Cite web | last =  | first =  | title = Part 8: Adult Advanced Cardiovascular Life Support | url = http://circ.ahajournals.org/content/122/18_suppl_3/S729.full | publisher =  | date =  | accessdate = 3 April 2014 }}</ref>
  | title = Ablation of paroxysmal tachycardia in Wolff-Parkinson-White syndrome
  | journal=Cardiologia
| volume=38| issue=12 Suppl 1| year=1993| pages=189-97
  | id=PMID 8020017
  | language = Italian }}</ref> If radiofrequency catheter ablation is successfully performed, the patient is generally considered cured. Recurrence rates are typically less than 5% after a successful ablation.<ref name = Pappone_et_al_1993 />  The one caveat is that individuals with underlying [[Ebstein's anomaly]] may develop additional accessory pathways during progression of their disease.


==Circus Movement Tachycardias==
==Long Term Treatment==
* Rapid heart rate is most likely due to CMT or atrial fibrillation.
'''Management of patients with [[AVRT]] includes 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>
* Palpitations are usually regular during a CMT, irregularly with atrial fib.
* Some patients report that their attacks of CMT may be broken by vagal maneuvers.
* A 24 hr holter should be done in those patients with a suspicion of WPW to assess the mode of initiation, and to determine the type (CMT vs afib).
* If the patients quality of life is affected and the holter is negative, then EP studies should be done.
* If there is an inability to induce CMT at EP then it is very unlikely that this is the arrhythmia that the patient is experiencing outside the hospital. Inability to induce CMT obviously does not exclude that the patient is experiencing afib.
* If the patient presents in a rapid rhythm, you should first try vagal maneuvers to terminate a CMT.
* The most likely arrhythmia on a statistical basis is a CMT with the AP conducting in a retrograde fashion. If the AP is incorporated in a retrograde fashion then there are often retrograde P waves apparent following the QRS, with a PR interval longer than the RP'interval.
* If the patient is known to have WPW and has a regular tachycardia thought to be a CMT, then verapamil should be the first drug used. If verapamil is not available, then use propranolol IV. Both terminate the CMT by prolonging the refractory period at the AV node.
* Digitalis has been used, however some patients may dev afib with this, and dig may abbreviate the refractory period of the AP resulting in higher ventricular rates during the afib. Therefore the use of dig is not recommended.
* If drugs affecting the AV node are not effective, then drugs that affect the accessory pathway are used such as procainamide or disopyramide.
* If the above fail to terminate the tachycardia or if the patient is tolerating the tachycardia poorly, then the patient should be paced out of it or cardioverted. Pacing is safer in patients on multiple drugs.


==Atrial Fibrillation==
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
* Patients can experience high rates during afib because of conduction over the accessory pathway which can have a very short refractory period.
|-
* Mean ventricular rates in these patients range from 160 to 300 BPM.
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for longterm  treatment of orthodromic AVRT'''
* During these attacks there is not only the risk of hemodynamic compromise but also a risk of degenerate into VF.
|-
* As a rule dig should be avoided in these patients.
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Catheter ablation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
* Cardioversion is the tx of choice. If the patient is receiving drugs that promote asystole following electrical cardioversion (e.g. verapamil, beta-blockers, and probably amiodarone) then a temporary pacer should be positioned in the RV before the cardioversion.
|-
* If the ventricular rate during the afib is not > 200, then you could try procainamide, disopyramide, or quinidine which may prolong the refractory period of the accessory pathway.
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Successful rate of ablation for [[AF]]+ [[AVRT]] is 93-95% <br>
❑ In young patients, the risk of recurrent [[AF]] after ablation of the accessory pathway is low<br>
❑ Recurrence of [[ AF]] in older patients after ablation may be related to other causes<br>
❑ Successful rate of ablation for [[mahain]] [[accessory pathway]] is 70-100%<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Oral [[beta blockers]], [[diltiazem]], [[verapamil]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Effective in patients without preexcitation in resting [[ECG]]<br>
❑ Prevention of [[AVRT]] recurrence in 50% patients<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Oral [[flecainide]] or [[propafenone]] ([[ACC AHA guidelines classification scheme|Class 2a, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑  For [[patients]] with [[AVRT]] and/or pre-excited [[AF]] that are not candidates or do not prefer [[catheter ablation]]<br>
❑ Mechanism of action is slowing or blocking conduction over the [[accessory pathway]]<br>
❑ Contraindications are ischemic or [[structural heart disease]] due to increased risk of [[VT]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Oral dofetilide or sotalol ([[ACC AHA guidelines classification scheme|Class 2b, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑  For patients with [[AVRT]] and/or pre-excited [[AF]] that are not candidated or do not prefer catheter ablation<br>
❑ Be useful in patients with structural heart disease or coronary artery disease<br>
❑ Side effect is [[QT ]] prolongation and [[torsades de poites]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Oral amiodarone ([[ACC AHA guidelines classification scheme|Class 2b, Level of Evidence C ]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ For [[patients]] with [[AVRT]] and/or pre-excited [[AF]] that are not candidated or do not prefer catheter ablation<br>
❑ For [[patients]] that using [[betablocker]], [[diltiazem]] or [[verapamil]] and [[flecainide]] are contraindicated or ineffective <br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Oral [[beta blockers]], [[diltiazem]], [[verapamil]] ([[ACC AHA guidelines classification scheme|Class 2b, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For patients with [[AVRT]] and/or pre-excited [[AF]] that are not candidates or do not prefer catheter ablation<br>
❑ Due to the risk of developing rapid [[AF]] in [[AVRT]], these drugs should be used with causion<br>
❑ Only one RCT supported  the use of [[verapamil]] for the prevention of orthodromic [[AVRT]] in patients with pre-excitation on resting [[ECG]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Oral [[digoxin]]  ([[ACC AHA guidelines classification scheme|Class 2b, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[AVRT]] without pre-excited [[AF]] that are not candidates or do not prefer catheter ablation<br>
❑  Because of low efficacy, in case of failure other [[antiarrhythmic]] agents, are recommended <br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Oral [[digoxin]]  ([[ACC AHA guidelines classification scheme|Class 3,Harm, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Harmful in [[AVRT]] or [[AF]] and preexcitation on resting [[ECG]] due to decreased refractory period of [[accessory pathway]] and increased risk of [[VF]]<br>
|}


==Approach to the Patient with a Questionable EKG==
* As mentioned previously, the diagnosis can be difficult in those patients c normal EKGs at rest.
* In some patients the diagnosis can be made with the following noninvasive procedures:
** CSP to increase the AV nodal delay therefore enhancing conduction over the accessory pathway.
** IV procainamide may cause QRS abnormality to disappear by prolonging conduction down the AP.
** β-blockers, verapamil, digoxin may also facilitate the conduction down the accessory pathway


==Intractable Tachyarrhythmias in WPW==
* In patients with afib with rapid ventricular response then surgical interruption should be considered.




<div align="left">
==Recommendations for the management of [[patients]] with asymptomatic [[pre-excitation]]==
<gallery heights="175" widths="175">
{| style="cellpadding=0; cellspacing= 0; width: 1200px;"
Image:Puzzle_2005_8_285_fig1.jpg|Figure 1: A 24 years old man with Mahaim type of preexcitation
|-
Image:Puzzle_2005_8_285_fig2.jpg|Figure 2: The same patient after Mahaim bundle ablation
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |
</gallery>
|-
</div>
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Performance of an [[electrophysiologic study]], with the use of [[isoprenaline]], is recommended to risk stratify individuals with asymptomatic pre-excitation who have high-risk [[occupations]]/[[hobbies]], or are competitive [[athletics]]<br>
❑[[Catheter ablation]] is recommended in asymptomatic [[patients]]  who are high risk in [[electrophysiology]] testing with the use of [[isoprenaline]], such as the shortest pre-excited [[RR interval]] during [[atrial fibrillation]]≤ 250 ms, [[accessory pathway]] [[effective refractory period]] ≤250 ms, multiple [[accessory pathway]]s, and an inducible [[accessory pathway]]-mediated [[tachycardia]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Catheter ablation]] is recommended in high-risk [[patients]] with asymptomatic pre-excitation after discussing the risks, especially of [[heart block]] associated with [[ablation]] of anteroseptal or mis-septal [[accessory pathway]], and benefits of the [[procedure]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''([[ESC guidelines classification scheme|Class 2a, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑  [[Patient]] should be clinically followed in the presence of asymptomatic pre-excitation and a low-risk [[accessory pathway]] at invasive [[risk stratification]]<br>
❑[[Catheter ablation]] should be considered in [[patients]] with asymptomatic pre-excitation and [[left ventricular dysfunction]] due to [[electrical dyssynchrony]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ESC guidelines classification scheme|Class 2b, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Catheter ablation]] may be considered in a [[patient]] with [[asymptomatic pre-excitation]], and a low-risk [[accessory pathway]] at invasive or non-invasive [[risk stratification]] <br>
❑ [[Catheter ablation]] may be considered in [[patients]] with low-risk asymptomatic pre-excitation in experienced centres according to [[patient]] preferences
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2019 ESC Guideline<ref name="pmid31504425">{{cite journal |vauthors=Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A |title=2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC) |journal=Eur Heart J |volume=41 |issue=5 |pages=655–720 |date=February 2020 |pmid=31504425 |doi=10.1093/eurheartj/ehz467 |url=}}</ref>
|-
|}


==References==
==References==

Latest revision as of 13:19, 18 August 2022

Wolff-Parkinson-White syndrome Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Rim Halaby, M.D. [4]

Overview

Wolff-Parkinson-White syndrome patients who are hemodynamically unstable, as reflected by the presence of hypotension, cold extremities, mottling or peripheral cyanosis, or those who present with ischemic chest pain or decompensated heart failure should urgently undergo direct current cardioversion. The medical therapy of hemodynamically stable patients with WPW syndrome depends on the type of the tachycardia. When the ECG findings suggest orthodromic AVRT, the patient should be managed similarly to patients with supreventricular tachycardia followed by the sequential administration of adenosine, verapamil and procainamide in case of failure to improve. Among patients with antidromic AVRT, AV nodal blocking agents should be avoided and patients should be treated with either procainamide, ibutilide or flecainide. The long term treatment of patients with WPW syndrome depends on the presence or absence of symptoms and their severity. Patients who have poorly tolerated symptomatic WPW syndrome should undergo [[catheter ablation.

Acute Treatment

Atrioventricular Reentrant Tachycardia (AVRT)

  • AVRT is one of the type of tachycardia that can occur in patients with WPW pattern.
  • AVRT can be either orthodromic or antidromic and the treatment of them is different.

Hemodynamically Unstable Patients

  • WPW syndrome patients with AVRT who are hemodynamically unstable,should urgently undergo direct current cardioversion
  • The signs of instability of hemodynamic include the following:
  • hypotension,
  • cold extremities
  • mottling
  • peripheral cyanosis
  • chest pain
  • decompensated heart failure
    • The shocks should be delivered as follows:
    • Narrow regular rhythm: synchronized electrical cardioversion, 50-100 Joules
    • Narrow irregular rhythm: synchronized electrical cardioversion, 120-200 Joules biphasic or 200 Joules monophasic
    • Wide regular rhythm: synchronized electrical cardioversion, 100 Joules
    • Wide irregular rhythm: unsynchronized electrical cardioversion, 200-360 Joules monophasic, or 100-200 Joules biphasic[1]

Orthodromic AVRT in Hemodynamically Stable Patients

The sequence of therapeutic decisions is summarized below.[2]

Recommendations for acute treatment of orthodromic AVRT
Vagal maneuver (Class I, Level of Evidence B):

Carotid sinus massage for 5-10 seconds in the absence of bruit
Valsalva maneuver for 10-30 seconds by bearing down against closed glottis, a more successful technique
❑ Applying ice-cold wet towel to the face

Adenosin(Class I, Level of Evidence B) :

❑ Effective in conversion of AVRT in 90-95% patients
❑ Episode of AVRT may be induced again by PAC or PVC after termination of tachyarrhythmia by adenosin
AF may be induced by adenosin, rapidly passing through accessory pathway Contraindications: asthma, second degree AV block or third degree AV block unless a pacemaker is present

Synchronized cardioversion : (Class I, Level of Evidence B)
❑ Highly effective in termination of AVRT

❑ In unstable hemodynamic or stable hemodynamic and ineffectiveness of vagal maneuver or adenosine is recommended
❑ Avoidance of complications associated antiarrhythmic drugs
❑ In the presence of PVC or PAC just after cardioversion, antiarrhythmic drugs is recommended for prevention of restarting AVRT
❑ In the presence of hemodynamically unstable and pre excited AF, synchronized cardioversion is recommended

Ibutilide or intravenous procainamide:(Class I, Level of Evidence C)

❑ effective in hemodynamic stable and preexcited AF by slowing conduction over the accessory pathway
Contraindications: Compromised left ventricular function

Intravenous diltiazem,verapamil ,beta blockers : (Class 2a, Level of Evidence B-C)

❑ Effective for acute treatment of orthodromic AVRT without pre-excitation on resting ECG during sinus rhythm(LOR=B)
❑ Intravenous diltiazem or verapamil effectively terminate 90% to 95% of AVRT without pre-excitation on their resting sinus-rhythm ECG
❑ Hypotension may occur in 3% patients receiving Intravenous diltiazem or verapamil
❑ Intravenous beta blocker are effective for terminating AVRT with low risk of associated complications(LOR=C)

Intravenous betablockers,diltiazem,verapamil (Class 2b, Level of Evidence B):

❑ Acute termination of orthodromic AVRT with pre-excitation on resting ECG without response to other treatment
❑ The complication is enhancing conduction over the accessory pathway if the AVRT converts to AF during the administration of the medication

Intravenous digoxin,intravenous amiodarone,intravenous or oral beta blockers,diltiazem,verapamil : (Class 3, Harm, Level of Evidence B)

❑ Harmful in acute termination of peexcitated AF due to increased risk of ventricular fibrillation by these mechanisms:
❑ Increased conduction over the accessory pathway and slowing or blocking conduction over AV node
❑ Deceased refractory period of accessory pathway by digoxin
❑ Increased cathecolamin due to drug induced hypotension such as amiodarone, beta blocker, verapamil, diltiazem

Antidromic AVRT in Hemodynamically Stable Patients

Treatment of Antidromic AVRT in Hemodynamically Stable Patients
Medication Dosage Notes
Procainamide 100 mg infusion diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes ❑ Give until the arrhythmia is suppressed or until 500 mg has been administered

❑ Wait 10 minutes or longer to administer new dosage
Contraindications: third degree AV block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes

Ibutilide 1 mg IV infusion over 10 minutes ❑ Repeat the dosage if the tachycardia continues

Contraindications: hypersensitivity to ibutilide or any component of the formulation, QTc >440 msec

Atrial Fibrillation

Hemodynamically Unstable Patients

In hemodynamically unstable patients, urgent direct current cardioversion should be performed.[1]

Long Term Treatment

Management of patients with AVRT includes the following:[2]

Recommendations for longterm treatment of orthodromic AVRT
Catheter ablation (Class I, Level of Evidence B):

❑ Successful rate of ablation for AF+ AVRT is 93-95%
❑ In young patients, the risk of recurrent AF after ablation of the accessory pathway is low
❑ Recurrence of AF in older patients after ablation may be related to other causes
❑ Successful rate of ablation for mahain accessory pathway is 70-100%

Oral beta blockers, diltiazem, verapamil (Class I, Level of Evidence C):

❑ Effective in patients without preexcitation in resting ECG
❑ Prevention of AVRT recurrence in 50% patients

Oral flecainide or propafenone (Class 2a, Level of Evidence B):

❑ For patients with AVRT and/or pre-excited AF that are not candidates or do not prefer catheter ablation
❑ Mechanism of action is slowing or blocking conduction over the accessory pathway
❑ Contraindications are ischemic or structural heart disease due to increased risk of VT

Oral dofetilide or sotalol (Class 2b, Level of Evidence C):

❑ For patients with AVRT and/or pre-excited AF that are not candidated or do not prefer catheter ablation
❑ Be useful in patients with structural heart disease or coronary artery disease
❑ Side effect is QT prolongation and torsades de poites

Oral amiodarone (Class 2b, Level of Evidence C ):

❑ For patients with AVRT and/or pre-excited AF that are not candidated or do not prefer catheter ablation
❑ For patients that using betablocker, diltiazem or verapamil and flecainide are contraindicated or ineffective

Oral beta blockers, diltiazem, verapamil (Class 2b, Level of Evidence C):

❑For patients with AVRT and/or pre-excited AF that are not candidates or do not prefer catheter ablation
❑ Due to the risk of developing rapid AF in AVRT, these drugs should be used with causion
❑ Only one RCT supported the use of verapamil for the prevention of orthodromic AVRT in patients with pre-excitation on resting ECG

Oral digoxin (Class 2b, Level of Evidence C):

❑ In AVRT without pre-excited AF that are not candidates or do not prefer catheter ablation
❑ Because of low efficacy, in case of failure other antiarrhythmic agents, are recommended

Oral digoxin (Class 3,Harm, Level of Evidence C):

❑ Harmful in AVRT or AF and preexcitation on resting ECG due to decreased refractory period of accessory pathway and increased risk of VF



Recommendations for the management of patients with asymptomatic pre-excitation

(Class I, Level of Evidence B):

❑Performance of an electrophysiologic study, with the use of isoprenaline, is recommended to risk stratify individuals with asymptomatic pre-excitation who have high-risk occupations/hobbies, or are competitive athletics
Catheter ablation is recommended in asymptomatic patients who are high risk in electrophysiology testing with the use of isoprenaline, such as the shortest pre-excited RR interval during atrial fibrillation≤ 250 ms, accessory pathway effective refractory period ≤250 ms, multiple accessory pathways, and an inducible accessory pathway-mediated tachycardia

(Class I, Level of Evidence C):

Catheter ablation is recommended in high-risk patients with asymptomatic pre-excitation after discussing the risks, especially of heart block associated with ablation of anteroseptal or mis-septal accessory pathway, and benefits of the procedure

(Class 2a, Level of Evidence C):

Patient should be clinically followed in the presence of asymptomatic pre-excitation and a low-risk accessory pathway at invasive risk stratification
Catheter ablation should be considered in patients with asymptomatic pre-excitation and left ventricular dysfunction due to electrical dyssynchrony

(Class 2b, Level of Evidence C):

Catheter ablation may be considered in a patient with asymptomatic pre-excitation, and a low-risk accessory pathway at invasive or non-invasive risk stratification
Catheter ablation may be considered in patients with low-risk asymptomatic pre-excitation in experienced centres according to patient preferences

The above table adopted from 2019 ESC Guideline[3]

References

  1. 1.0 1.1 "Part 8: Adult Advanced Cardiovascular Life Support". Retrieved 3 April 2014.
  2. 2.0 2.1 2.2 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.
  3. Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A (February 2020). "2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC)". Eur Heart J. 41 (5): 655–720. doi:10.1093/eurheartj/ehz467. PMID 31504425.

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