Wolff-Parkinson-White syndrome resident survival guide: Difference between revisions
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Wolff-Parkinson-White syndrome resident survival guide#Causes|Causes]] | ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Wolff-Parkinson-White syndrome resident survival guide#Causes|Causes]] | ||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | | ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Wolff-Parkinson-White syndrome resident survival guide#Focused Initial Rapid Evaluation|FIRE]] | ||
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:[[Wolff-Parkinson-White syndrome resident survival guide#Complete Diagnostic Approach | ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Wolff-Parkinson-White syndrome resident survival guide#Complete Diagnostic Approach|Complete Diagnostic Approach]] | ||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Wolff-Parkinson-White syndrome resident survival guide#Treatment|Treatment]] | ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Wolff-Parkinson-White syndrome resident survival guide#Treatment|Treatment]] | ||
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* [[Congenital]] | * [[Congenital]] | ||
==FIRE: Focused Initial Rapid Evaluation | ==FIRE: Focused Initial Rapid Evaluation== | ||
The aim of FIRE is to identify urgent conditions that require immediate intervention. In [[Wolff-Parkinson-White syndrome]], hemodynamic isntability should be ruled out because it requires urgent electrical [[cardioversion]].<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher = | date = | accessdate = 15 August 2013 }}</ref><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> | |||
{{Family tree/start}} | {{Family tree/start}} | ||
{{familytree | | | | | | | | | | | | | E01 | | | | | | | | | E01= <div style="float: left; text-align: left; width: 28em; padding:1em;">'''Identify cardinal | {{familytree | | | | | | | | | | | | | E01 | | | | | | | | | E01= <div style="float: left; text-align: left; width: 28em; padding:1em;">'''Identify cardinal findings that increase the pretest probability of Wolff-Parkinson-White syndrome'''<br> ❑ Palpitsations <br> ❑ Chest discomfort <br> ❑ Regular rhythm <br> ❑ Rate over 150 bpm <br> ❑ Orthodrome AVRT: [[narrow QRS complex]] preceded by a [[p-wave]] <br>❑ Antidrome AVRT: [[wide QRS complex]] followed by a retrograde [[p-wave]]</div>}} | ||
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | }} | {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | }} | ||
{{familytree | | | | | | | | | | | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 28em; padding:1em;">''' | {{familytree | | | | | | | | | | | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 28em; padding:1em;">'''Does the patient have any of the following findings that require urgent cardioversion?''' <br> | ||
❑ [[ | ❑ Hemodynamic instability | ||
</div>}} | :❑ [[Hypotension]] | ||
:❑ Cold extremities | |||
:❑ [[Cyanosis|Peripheral cyanosis]] | |||
:❑ Mottling | |||
:❑ [[Altered mental status]] | |||
❑ [[Chest discomfort]] suggestive of [[ischemia]] <br> | |||
❑ [[Heart failure|Decompensated heart failure]]<br></div>}} | |||
{{familytree | | | | | | | | | | |,|-|-|^|-|-|.| | | | |}} | {{familytree | | | | | | | | | | |,|-|-|^|-|-|.| | | | |}} | ||
{{familytree | | | | | | | | | | B01 | | | | B02 | | | | B01=<div style=" background: #F60A0A"> {{fontcolor|#F8F8FF|'''Hemodynamic instability present'''}}</div> | B02= '''Hemodynamic instability absent'''}} | {{familytree | | | | | | | | | | B01 | | | | B02 | | | | B01=<div style=" background: #F60A0A"> {{fontcolor|#F8F8FF|'''Hemodynamic instability present'''}}</div> | B02= '''Hemodynamic instability absent'''}} | ||
{{familytree | | | | | | | | | | |!| | | | | |!| | | | }} | {{familytree | | | | | | | | | | |!| | | | | |!| | | | }} | ||
{{familytree | | | | | | | | | | C01 | | | | C02 | | | | C01=<div style=" background: #FF0000; text-align: left"> {{fontcolor|#F8F8FF| ❑ Assess airway, breathing, and circulation ([[ABC (medical)|<span style="color:white;">ABC</span>]])}} </div> | C02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Wolff-Parkinson-White syndrome resident survival guide#Complete Diagnostic Approach of Wolff-Parkinson-White syndrome|Continue with the diagnostic approach]]''' </div>}} | {{familytree | | | | | | | | | | C01 | | | | C02 | | | | C01=<div style=" background: #FF0000; text-align: left"> {{fontcolor|#F8F8FF| ❑ Assess airway, breathing, and circulation ([[ABC (medical)|<span style="color:white;">ABC</span>]])}} </div> | C02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Wolff-Parkinson-White syndrome resident survival guide#Complete Diagnostic Approach of Wolff-Parkinson-White syndrome|Continue with the diagnostic approach below]]''' </div>}} | ||
{{familytree | | | | | | | | | | |!| | | | | | | | | | }} | {{familytree | | | | | | | | | | |!| | | | | | | | | | }} | ||
{{familytree | | | | | | | | | | G01 | | | | | | | | | G01=<div style=" background: #F60A0A; text-align: left; width: 22em"> {{fontcolor|#F8F8FF| ❑ Perform | {{familytree | | | | | | | | | | G01 | | | | | | | | | G01=<div style=" background: #F60A0A; text-align: left; width: 22em"> {{fontcolor|#F8F8FF| ❑ Perform sychronized electrical cardioversion}}<br> | ||
:❑ Narrow regular rhythm: 50-100 Joules<br> | |||
:❑ Narrow irregular rhythm: 120-200 Joules biphasic or 200 Joules monophasic}}<br> | |||
:❑ Wide regular rhythm: 100 Joules<br> | |||
:❑ Wide irregular rhythm: defibrillation<br> | |||
</div>}} | |||
{{familytree | | | | | | | | | | |!| | | | | | | | | |}} | {{familytree | | | | | | | | | | |!| | | | | | | | | |}} | ||
{{familytree | | | | | | | | | | M01 | | | | | | |M01=<div style=" background: #F60A0A; text-align: left; width: 22em"> {{fontcolor|#F8F8FF|❑ Administer [[oxygen|<span style="color:white;"> oxygen </span>]] if necessary}} </div>}} | {{familytree | | | | | | | | | | M01 | | | | | | |M01=<div style=" background: #F60A0A; text-align: left; width: 22em"> {{fontcolor|#F8F8FF|❑ Administer [[oxygen|<span style="color:white;"> oxygen </span>]] if necessary}} </div>| | ||
{{familytree | | | |!| | | | | }} | |||
{{familytree | | | D01 | | | | D01= ❑ '''[[Wolff-Parkinson-White syndrome resident survival guide#Complete Diagnostic Approach|After stabilizing the patient, continue with the complete diagnostic approach below]]'''}} | |||
{{familytree/end}} | {{familytree/end}} | ||
<br> | |||
==Complete Diagnostic Approach | ==Complete Diagnostic Approach== | ||
Shown below is | Shown below is a complete algorithm summarizing the diagnostic approach to [[Wolff-Parkinson-White syndrome]] according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias.<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher = | date = | accessdate = 15 August 2013 }}</ref> | ||
<span style="font-size:85%"> '''Abbreviations:''' '''AVRT''': [[AV reentrant tachycardia]]; '''BP:''' [[blood pressure]]; '''AF:''' [[atrial fibrillation]] '''HF:''' [[heart failure]] '''LVH:''' [[left ventricular hypertrophy]]; '''ECG:''' [[electrocardiography]] </span> | <span style="font-size:85%"> '''Abbreviations:''' '''AVRT''': [[AV reentrant tachycardia]]; '''BP:''' [[blood pressure]]; '''AF:''' [[atrial fibrillation]] '''HF:''' [[heart failure]] '''LVH:''' [[left ventricular hypertrophy]]; '''ECG:''' [[electrocardiography]] </span> | ||
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{{familytree | |,|-|-|-|+|-|-|-|.| | | |}} | {{familytree | |,|-|-|-|+|-|-|-|.| | | |}} | ||
{{familytree | D01 | | D02 | | D03 | | | D01= <div style="float: left; text-align: left; width: 24em; padding:1em;">'''[[WPW]] with [[AF]]'''<br> | {{familytree | D01 | | D02 | | D03 | | | D01= <div style="float: left; text-align: left; width: 24em; padding:1em;">'''[[WPW]] with [[AF]]'''<br> | ||
Suspect when [[AF]] appears with heart rates of 220 to 360<br> | Suspect when [[AF]] appears with heart rates of 220 to 360.<br> | ||
'''[[EKG]] findings'''<ref name="FenglerBrady2007">{{cite journal|last1=Fengler|first1=Brian T.|last2=Brady|first2=William J.|last3=Plautz|first3=Claire U.|title=Atrial fibrillation in the Wolff-Parkinson-White syndrome: ECG recognition and treatment in the ED|journal=The American Journal of Emergency Medicine|volume=25|issue=5|year=2007|pages=576–583|issn=07356757|doi=10.1016/j.ajem.2006.10.017}}</ref><br> | '''[[EKG]] findings'''<ref name="FenglerBrady2007">{{cite journal|last1=Fengler|first1=Brian T.|last2=Brady|first2=William J.|last3=Plautz|first3=Claire U.|title=Atrial fibrillation in the Wolff-Parkinson-White syndrome: ECG recognition and treatment in the ED|journal=The American Journal of Emergency Medicine|volume=25|issue=5|year=2007|pages=576–583|issn=07356757|doi=10.1016/j.ajem.2006.10.017}}</ref><br> | ||
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{{familytree | | | D01 | | | | D02 | | | | D01= '''Stable patient'''| D02= '''Unstable patient'''}} | {{familytree | | | D01 | | | | D02 | | | | D01= '''Stable patient'''| D02= '''Unstable patient'''}} | ||
{{familytree | | | |!| | | | | |!| | | | }} | {{familytree | | | |!| | | | | |!| | | | }} | ||
{{familytree | | | E01 | | | | E02 | | | | E01= <div style="float: left; text-align: left"> ❑ Assess the [[ECG]] </div>| | {{familytree | | | E01 | | | | E02 | | | | E01=<div style="float: left; text-align: left"> ❑ Assess the [[ECG]] </div>| | ||
E02= <div style="float: left; text-align: left; width: 24em"><br> | E02=<div style="float: left; text-align: left; width: 24em"><br> ❑ Urgent electrical [[cardioversion]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])<br>''And/Or''<br> ❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br> | ||
❑ Urgent electrical [[cardioversion]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]]) | |||
❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br> | |||
</div>}} | </div>}} | ||
{{familytree | |,|-|^|-|.| | | | | }} | {{familytree | |,|-|^|-|.| | | | | }} | ||
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: ❑ If initial dose is not effective, administer a second dose of 12 mg, repeated a second time if required<br> | : ❑ If initial dose is not effective, administer a second dose of 12 mg, repeated a second time if required<br> | ||
:<span style="font-size:85%;color:red">Contraindications: second- or third-degree A-V block (except in patients with a functioning artificial pacemaker<br></span><br> | :<span style="font-size:85%;color:red">Contraindications: second- or third-degree A-V block (except in patients with a functioning artificial pacemaker<br></span><br> | ||
''If not effective''<br> | |||
❑ Administer [[verapamil]] 5 to 10 mg (0.075 to 0.15 mg/kg body weight) IV boluses of over 2 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]])<br> | ❑ Administer [[verapamil]] 5 to 10 mg (0.075 to 0.15 mg/kg body weight) IV boluses of over 2 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]])<br> | ||
: ❑ Give 30% of the dose in case of hepatic impairment<br> | : ❑ Give 30% of the dose in case of hepatic impairment<br> | ||
: ❑ Monitor for prolonged PR interval in case of renal impairment<br> | : ❑ Monitor for prolonged PR interval in case of renal impairment<br> | ||
:<span style="font-size:85%;color:red">Contraindications: severe left ventricular dysfunction, hypotension (systolic pressure less than 90 mm Hg) or cardiogenic shock</span><br> | :<span style="font-size:85%;color:red">Contraindications: severe left ventricular dysfunction, hypotension (systolic pressure less than 90 mm Hg) or cardiogenic shock</span><br> | ||
''If not effective''<br> | |||
❑ Administer [[procainamide]], 100 mg infusion diluted to 100mg/ml at a rate of 50 mg/min every 5 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br> | ❑ Administer [[procainamide]], 100 mg infusion diluted to 100mg/ml at a rate of 50 mg/min every 5 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br> | ||
:❑ Give until the arrhythmia is suppressed or up to 500 mg <br> | :❑ Give until the arrhythmia is suppressed or up to 500 mg <br> | ||
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::❑ Repeat the dosage if the tachycardia continues <br> | ::❑ Repeat the dosage if the tachycardia continues <br> | ||
::<span style="font-size:85%;color:red">Contraindications: hypersensitivity to ibutilide or any component of the formulation, QTc >440 msec</span><br> | ::<span style="font-size:85%;color:red">Contraindications: hypersensitivity to ibutilide or any component of the formulation, QTc >440 msec</span><br> | ||
''Or''<br> | |||
❑ Administer [[procainamide]], 100 mg infusion diluted to 100mg/ml at a rate of 50 mg/min every 5 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br> | ❑ Administer [[procainamide]], 100 mg infusion diluted to 100mg/ml at a rate of 50 mg/min every 5 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br> | ||
::❑ Give until the arrhythmia is suppressed or until 500 mg has been administered<br> | ::❑ Give until the arrhythmia is suppressed or until 500 mg has been administered<br> | ||
::❑ Wait 10 minutes or longer to administer new dosage | ::❑ Wait 10 minutes or longer to administer new dosage | ||
::<span style="font-size:85%;color:red">Contraindications: complete heart block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes</span><br> | ::<span style="font-size:85%;color:red">Contraindications: complete heart block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes</span><br> | ||
''Or''<br> | |||
❑ Administer [[adenosine]] 6 mg IV (bolus) <br> | ❑ Administer [[adenosine]] 6 mg IV (bolus) <br> | ||
:❑ If initial dose is not effective, administer a second dose of 12 mg, repeated a second time if required<br> | :❑ If initial dose is not effective, administer a second dose of 12 mg, repeated a second time if required<br> | ||
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::❑ Repeat the dosage if the tachycardia continues <br> | ::❑ Repeat the dosage if the tachycardia continues <br> | ||
::<span style="font-size:85%;color:red">Contraindications: hypersensitivity to ibutilide or any component of the formulation, QTc >440 msec</span><br> | ::<span style="font-size:85%;color:red">Contraindications: hypersensitivity to ibutilide or any component of the formulation, QTc >440 msec</span><br> | ||
''Or''<br> | |||
:❑ Administer [[procainamide]] 100 mg infusion diluted to 100mg/ml at a rate of 50 mg/min every 5 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br> | :❑ Administer [[procainamide]] 100 mg infusion diluted to 100mg/ml at a rate of 50 mg/min every 5 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br> | ||
::❑ Give until the arrhythmia is suppressed or up to 500 mg<br> | ::❑ Give until the arrhythmia is suppressed or up to 500 mg<br> | ||
::❑ Wait 10 minutes to administer new dosage | ::❑ Wait 10 minutes to administer new dosage | ||
::<span style="font-size:85%;color:red">Contraindications: complete heart block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes</span><br> | ::<span style="font-size:85%;color:red">Contraindications: complete heart block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes</span><br> | ||
''Or''<br> | |||
:❑ Administer [[amiodarone]] 15 mg/min in 10 minutes ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence B]])<br> | :❑ Administer [[amiodarone]] 15 mg/min in 10 minutes ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence B]])<br> | ||
::❑ Then, 1mg/min for 6 hours <br> | ::❑ Then, 1mg/min for 6 hours <br> | ||
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</div> | | </div> | | ||
C02= <div style="float: left; text-align: left; width: 27em; padding:1em;"> | C02= <div style="float: left; text-align: left; width: 27em; padding:1em;"> | ||
❑ Urgent electric [[cardioversion]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) | ❑ Urgent electric [[cardioversion]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br>''And/Or''<br> | ||
❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br> | ❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br> | ||
</div>}} | </div>}} | ||
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{{familytree | |,|-|-|-|-|+|-|-|-|-|-|-|.| | |}} | {{familytree | |,|-|-|-|-|+|-|-|-|-|-|-|.| | |}} | ||
{{familytree | B01 | | | B02 | | | | | B03 | | B01= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Single or infrequent episodes'''<br> | {{familytree | B01 | | | B02 | | | | | B03 | | B01= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Single or infrequent episodes'''<br> | ||
❑ No treatment ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]]) | ❑ No treatment ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]]) <br>''And''<br> | ||
❑ [[Vagal maneuvers]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) | ❑ [[Vagal maneuvers]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) <br>''Or''<br> | ||
❑ Single dose treatment (pill-in-the-pocket): verapamil, dialtizem or beta blockers ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) | ❑ Single dose treatment (pill-in-the-pocket): verapamil, dialtizem or beta blockers ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br>''Or''<br> | ||
❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) | ❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) <br>''Or''<br> | ||
❑ [[Sotalol]] or [[amiodarone]] ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence B]]) | ❑ [[Sotalol]] or [[amiodarone]] ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence B]]) <br>''Or''<br> | ||
❑ [[Flecainide]] or [[propofenone]] ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence C]])<br><br> | ❑ [[Flecainide]] or [[propofenone]] ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence C]])<br><br> | ||
❑ <span style="font-size:100%;color:red">Avoid AV blocking agents such as: digoxin, verapamil, dialtizem</span>([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])<br> | ❑ <span style="font-size:100%;color:red">Avoid AV blocking agents such as: digoxin, verapamil, dialtizem</span>([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])<br> | ||
</div> | | </div> | | ||
B02= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Recurrent episodes'''<br> | B02= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Recurrent episodes'''<br> | ||
❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) | ❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br>''Or''<br> | ||
❑ [[Antiarrhythmic agents|Class IC antiarrhythmic agents]] such as: [[flecainide]], [[propafenone]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence C]]) | ❑ [[Antiarrhythmic agents|Class IC antiarrhythmic agents]] such as: [[flecainide]], [[propafenone]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence C]])<br>''Or''<br> | ||
❑ [[Sotalol]],[[amiodarone]] or [[beta blockers]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence C]])<br><br> | ❑ [[Sotalol]],[[amiodarone]] or [[beta blockers]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence C]])<br><br> | ||
❑ <span style="font-size:100%;color:red">Avoid AV blocking agents such as: digoxin, verapamil, dialtizem</span> ([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])<br> | ❑ <span style="font-size:100%;color:red">Avoid AV blocking agents such as: digoxin, verapamil, dialtizem</span> ([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])<br> | ||
</div> | | </div> | | ||
B03= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Asymptomatic''' <br> | B03= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Asymptomatic''' <br> | ||
❑ No treatment ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]]) | ❑ No treatment ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]]) <br>''Or''<br> | ||
❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) <br> | ❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) <br> | ||
</div>}} | </div>}} |
Revision as of 17:36, 4 April 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hilda Mahmoudi M.D., M.P.H.[2]; Alonso Alvarado, M.D.; Alejandro Lemor, M.D. [3]
Synonyms and keywords: WPW syndrome, WPW pattern
Wolff-Parkinson-White Syndrome Resident Survival Guide Microchapters |
---|
Overview |
Causes |
FIRE |
Complete Diagnostic Approach |
Treatment |
Do's |
Don'ts |
Overview
Wolff-Parkinson-White (WPW) syndrome is a condition of pre-excitation of the ventricles of the heart due to the presence of an accessory pathway known as the Bundle of Kent through which the electrical impulses bypass the AV node. The difference between WPW pattern and WPW syndrome is that WPW pattern is characterized by the presence of characteristic ECG findings, such as a short PR interval and a delta wave, whereas WPW syndrome is the occurrence of tachycardia with or without associated symptoms in a subject with existing WPW pattern.[1] The treatment of WPW syndrome is targeted towards the restoration of the sinus rhythm, usually by the administration of either ibutilide or procainamide. The most common type of arrhythmia in WPW syndrome is AV reentrant tachycardia.[2] Atrial fibrillation in a patient with WPW is life threatening and should be managed urgently. Atrial fibrillation in a patient with WPW should be suspected when there is ECG findings suggestive of atrial fibrillation in the context of a heart rate higher than 220 beats per minute.
Causes
Life Threatening Causes
Wolff-Parkinson-White syndrome can be a life-threatening condition and must be treated as such irrespective of the underlying cause.
Common Causes
FIRE: Focused Initial Rapid Evaluation
The aim of FIRE is to identify urgent conditions that require immediate intervention. In Wolff-Parkinson-White syndrome, hemodynamic isntability should be ruled out because it requires urgent electrical cardioversion.[2][3]
Identify cardinal findings that increase the pretest probability of Wolff-Parkinson-White syndrome ❑ Palpitsations ❑ Chest discomfort ❑ Regular rhythm ❑ Rate over 150 bpm ❑ Orthodrome AVRT: narrow QRS complex preceded by a p-wave ❑ Antidrome AVRT: wide QRS complex followed by a retrograde p-wave | |||||||||||||||||||||||||||||||||||||||||||||||
Does the patient have any of the following findings that require urgent cardioversion? ❑ Hemodynamic instability
❑ Chest discomfort suggestive of ischemia | |||||||||||||||||||||||||||||||||||||||||||||||
Hemodynamic instability present | Hemodynamic instability absent | ||||||||||||||||||||||||||||||||||||||||||||||
❑ Assess airway, breathing, and circulation (ABC) | |||||||||||||||||||||||||||||||||||||||||||||||
❑ Perform sychronized electrical cardioversion
| |||||||||||||||||||||||||||||||||||||||||||||||
❑ After stabilizing the patient, continue with the complete diagnostic approach below | |||||||||||||||||||||||||||||||||||||||||||||||
Complete Diagnostic Approach
Shown below is a complete algorithm summarizing the diagnostic approach to Wolff-Parkinson-White syndrome according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias.[2]
Abbreviations: AVRT: AV reentrant tachycardia; BP: blood pressure; AF: atrial fibrillation HF: heart failure LVH: left ventricular hypertrophy; ECG: electrocardiography
Characterize the symptoms: ❑ Asymptomatic
❑ Duration
| |||||||||||||||||||||||||||
Identify possible triggers: ❑ Infection | |||||||||||||||||||||||||||
Examine the patient: Appearance of the patient Vitals
Cardiovascular | |||||||||||||||||||||||||||
Order studies: ❑ ECG | |||||||||||||||||||||||||||
Orthodromic AVRT The anterograde conduction (from the atrium to the ventricle) passes through the AV node and the retrograde conduction (from the ventricle to the atrium) passes through the accessory pathway. It apprears in 90 to 95% of WPW. EKG findings: | Antidromic AVRT The anterograde conduction (from the atrium to the ventricle) passes through the accessory pathway and the retrograde conduction (from the ventricle to the atrium) passes through the AV node. It apprears in less than 10% of WPW. EKG findings: | ||||||||||||||||||||||||||
Treatment
Initial Treatment
Shown below is an algorithm summarizing the initial approach to Wolff-Parkinson-White syndrome according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias.[2]
Determine if the patient has any unstable signs or symptoms ❑ Chest pain | |||||||||||||||||||||||||||||
Stable patient | Unstable patient | ||||||||||||||||||||||||||||
❑ Assess the ECG | ❑ Urgent electrical cardioversion (Class I, Level of Evidence C) And/Or ❑ Catheter ablation (Class I, Level of Evidence B) | ||||||||||||||||||||||||||||
Orthodromic AVRT | Antidromic AVRT | ||||||||||||||||||||||||||||
❑ Use vagal maneuvers (Class I, Level of Evidence B)
If not effective
If not effective
| Avoid the use of av blocking agents such as digoxin, verapamil or diltiazem ❑ Administer ibutilide 1 mg IV infusion over 10 minutes (Class I, Level of Evidence B)
Or
Or
| ||||||||||||||||||||||||||||
Wolff-Parkinson-White Syndrome with Atrial Fibrillation
Atrial fibrillation in a patient with WPW should be suspected when the the heart rate of a patient with WPW is between 220 and 360 bpm. Shown below is an algorithm summarizing the managment of Wolff-Parkinson-White syndrome with atrial fibrillation according to the ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation.[5]
Determine if the patient has any unstable signs or symptoms ❑ Chest pain | |||||||||||||||||||||||||||
Stable patient | Unstable patient | ||||||||||||||||||||||||||
Avoid the use of AV node blocking agents such as digoxin, verapamil or diltizem
Or
Or
| ❑ Urgent electric cardioversion (Class I, Level of Evidence B) | ||||||||||||||||||||||||||
Long-Term Treatment
Shown below is an algorithm summarizing the long-term treatment of Wolff-Parkinson-White syndrome.
Do's
- Perform catheter ablation of the accessory pathway if possible (class I, level of evidence B).
- Electrical cardioversion can be performed in cases of WPW with AF with rapid ventricular response (class II, level of evidence A).
- In asymptomatic patients, either no intervention (class I, level of evidence C) or catheter ablation (class IIb, level of evidence B) could be performed.
- Prescribe propafenone over flecainide for the prevention of recurrence orthodromic AVRT as it has also a mild beta blocking activity.
- Schedule exercise stress test and electrophysiology tests for the sudden cardiac death stratification (class IIa, level of evidence B).
- Consider catheter ablation in asymptomatic patients with structural heart disease (class IIb, level of evidence C).
Don'ts
- Don't use AV blocking agents in patients with WPW and antidromic AVRT as it will promote promote conduction down the accessory pathway (class III, level of evidence C).[6]
- Avoid the usage of AV blocking agents in patients with WPW and AF (class III, level of evidence B).
- Avoid AV blocking agents (such as digoxin, verapamil or diltiazem) as chronic treatment to prevent the recurrence of tachycardia (class III, level of evidence B).
References
- ↑ "Wolff-Parkinson-White Syndrome and Accessory Pathways". Retrieved 1 April 2014.
- ↑ 2.0 2.1 2.2 2.3 "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.
- ↑ "Part 8: Adult Advanced Cardiovascular Life Support". Retrieved 3 April 2014.
- ↑ Fengler, Brian T.; Brady, William J.; Plautz, Claire U. (2007). "Atrial fibrillation in the Wolff-Parkinson-White syndrome: ECG recognition and treatment in the ED". The American Journal of Emergency Medicine. 25 (5): 576–583. doi:10.1016/j.ajem.2006.10.017. ISSN 0735-6757.
- ↑ Fuster, V.; Rydén, LE.; Cannom, DS.; Crijns, HJ.; Curtis, AB.; Ellenbogen, KA.; Halperin, JL.; Le Heuzey, JY.; Kay, GN. (2006). "ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation. 114 (7): e257–354. doi:10.1161/CIRCULATIONAHA.106.177292. PMID 16908781. Unknown parameter
|month=
ignored (help) - ↑ Garratt, C.; Antoniou, A.; Ward, D.; Camm, AJ. (1989). "Misuse of verapamil in pre-excited atrial fibrillation". Lancet. 1 (8634): 367–9. PMID 2563516. Unknown parameter
|month=
ignored (help) - ↑ Gulamhusein, S.; Ko, P.; Carruthers, SG.; Klein, GJ. (1982). "Acceleration of the ventricular response during atrial fibrillation in the Wolff-Parkinson-White syndrome after verapamil". Circulation. 65 (2): 348–54. PMID 7053894. Unknown parameter
|month=
ignored (help) - ↑ McGovern, B.; Garan, H.; Ruskin, JN. (1986). "Precipitation of cardiac arrest by verapamil in patients with Wolff-Parkinson-White syndrome". Ann Intern Med. 104 (6): 791–4. PMID 3706931. Unknown parameter
|month=
ignored (help)