Wolff-Parkinson-White syndrome resident survival guide: Difference between revisions
Line 216: | Line 216: | ||
{{familytree | G00 | | G01 | | G02 | | | |G00= <div style="float: left; text-align: left; width: 27em; padding:1em;"> | {{familytree | G00 | | G01 | | G02 | | | |G00= <div style="float: left; text-align: left; width: 27em; padding:1em;"> | ||
<span style="font-size:100%;color:red"> '''Avoid the use of AV node blocking agents such as digoxin, calcium channel blockers, beta blockers and adenosine.'''</span><br><br> | <span style="font-size:100%;color:red"> '''Avoid the use of AV node blocking agents such as digoxin, calcium channel blockers, beta blockers and adenosine.'''</span><br><br> | ||
❑ Administer [[procainamide]], 100 mg infusion diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])<ref name="pmid23545139">{{cite journal| author=American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB et al.| title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 18 | pages= 1916-26 | pmid=23545139 | doi=10.1161/CIR.0b013e318290826d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23545139 }} </ref><br> | ❑ Administer [[procainamide]], 100 mg [[infusion]] diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])<ref name="pmid23545139">{{cite journal| author=American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB et al.| title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 18 | pages= 1916-26 | pmid=23545139 | doi=10.1161/CIR.0b013e318290826d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23545139 }} </ref><br> | ||
:❑ Administer until the [[arrhythmia]] is suppressed or until 500 mg has been administered<br> | :❑ Administer 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 [[ibutilide]] 1 mg IV infusion over 10 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])<ref name="pmid23545139">{{cite journal| author=American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB et al.| title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 18 | pages= 1916-26 | pmid=23545139 | doi=10.1161/CIR.0b013e318290826d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23545139 }} </ref><br> | ''Or''<br>❑ Administer [[ibutilide]] 1 mg IV [[infusion]] over 10 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])<ref name="pmid23545139">{{cite journal| author=American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB et al.| title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 18 | pages= 1916-26 | pmid=23545139 | doi=10.1161/CIR.0b013e318290826d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23545139 }} </ref><br> | ||
:❑ 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> | ''Or''<br> | ||
❑ Administer [[flecainide]] 50 mg every 12 hours ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])<ref name="pmid23545139">{{cite journal| author=American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB et al.| title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 18 | pages= 1916-26 | pmid=23545139 | doi=10.1161/CIR.0b013e318290826d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23545139 }} </ref> | ❑ Administer [[flecainide]] 50 mg every 12 hours ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])<ref name="pmid23545139">{{cite journal| author=American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB et al.| title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 18 | pages= 1916-26 | pmid=23545139 | doi=10.1161/CIR.0b013e318290826d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23545139 }} </ref> | ||
:❑ Increase 50mg BID every four days until efficacy is achieved <br> | :❑ Increase 50mg BID every four days until efficacy is achieved <br> | ||
:❑ Maximum dose recommended for [[SVT]] is 300 mg/day<br> | :❑ Maximum [[dose]] recommended for [[SVT]] is 300 mg/day<br> | ||
:<span style="font-size:85%;color:red">Contraindications: pre-existing second- or third-degree AV block, right bundle branch block associated with a left hemiblock unless a pacemaker is present, cardiogenic shock, hypersensitivity to the drug</span><br> | :<span style="font-size:85%;color:red">Contraindications: pre-existing second- or third-degree AV block, right bundle branch block associated with a left hemiblock unless a pacemaker is present, cardiogenic shock, hypersensitivity to the drug</span><br> | ||
</div> | </div> | ||
Line 235: | Line 235: | ||
<br>''If not effective initiate IV AV nodal blocking agent''<br><br> | <br>''If not effective initiate IV AV nodal blocking agent''<br><br> | ||
❑ Administer [[adenosine]] 6 mg IV (bolus) ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]])<br> | ❑ Administer [[adenosine]] 6 mg IV (bolus) ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]])<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> | ||
:<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><br> | ''If not effective''<br><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 [[Bolus|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><br> | ''If not effective''<br><br> | ||
❑ Administer [[procainamide]], 100 mg infusion diluted to 100mg/ml at a rate of 25-50 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 25-50 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 or longer to administer new dosage <br> | :❑ Wait 10 minutes or longer to administer new dosage <br> | ||
:❑ Dosage should be adjusted for the individual patient in case of renal impairment<br> | :❑ [[Dosage]] should be adjusted for the individual patient in case of [[renal impairment]]<br> | ||
:<span style="font-size:85%;color:red">Contraindications: complete heart block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes</span><br></div> | :<span style="font-size:85%;color:red">Contraindications: complete heart block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes</span><br></div> | ||
| G02= <div style="float: left; text-align: left; width: 24em; padding:1em;"><br> | | G02= <div style="float: left; text-align: left; width: 24em; padding:1em;"><br> | ||
<span style="font-size:100%;color:red"> '''Avoid the use of AV node blocking agents such as digoxin, calcium channel blockers, beta blockers and adenosine.'''</span><br><br> | <span style="font-size:100%;color:red"> '''Avoid the use of AV node blocking agents such as digoxin, calcium channel blockers, beta blockers and adenosine.'''</span><br><br> | ||
❑ Administer [[procainamide]], 100 mg infusion diluted to 100mg/ml at a rate of 25-50 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 25-50 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 [[ibutilide]] 1 mg IV infusion over 10 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br> | ''Or''<br>❑ Administer [[ibutilide]] 1 mg IV infusion over 10 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br> | ||
:❑ 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> | ''Or''<br> | ||
❑ Administer [[flecainide]] 50 mg every 12 hours | ❑ Administer [[flecainide]] 50 mg every 12 hours | ||
:❑ Increase 50mg BID every four days until efficacy is achieved <br> | :❑ Increase 50mg BID every four days until efficacy is achieved <br> | ||
:❑ Maximum dose recommended for [[SVT]] is 300 mg/day<br> | :❑ Maximum [[dose]] recommended for [[SVT]] is 300 mg/day<br> | ||
:<span style="font-size:85%;color:red">Contraindications: pre-existing second- or third-degree AV block, right bundle branch block associated with a left hemiblock unless a pacemaker is present, cardiogenic shock, hypersensitivity to the drug</span><br> | :<span style="font-size:85%;color:red">Contraindications: pre-existing second- or third-degree AV block, right bundle branch block associated with a left hemiblock unless a pacemaker is present, cardiogenic shock, hypersensitivity to the drug</span><br> | ||
</div>}} | </div>}} |
Revision as of 13:44, 18 April 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D.; Hilda Mahmoudi M.D., M.P.H.[2]; Alejandro Lemor, M.D. [3]
Wolff-Parkinson-White Syndrome Resident Survival Guide Microchapters |
---|
Overview |
Causes |
FIRE |
Diagnosis |
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
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[2][3]
Boxes in salmon color signify that an urgent management is needed.
Identify cardinal findings that increase the pretest probability of Wolff-Parkinson-White syndrome ❑ Baseline ECG findings suggestive of WPW pattern (pre-excitation)
AND
ECG findings suggestive of AF + WPW
| |||||||||||||||||||||||||||||||
Does the patient have any of the following findings that require urgent cardioversion? ❑ Hemodynamic instability ❑ Chest discomfort suggestive of ischemia | |||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||
Does the patient have a wide irregular rhythm? | |||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||
❑ Perform urgent unsynchronized electrical cardioversion
| ❑ Perform urgent synchronized electrical cardioversion | ||||||||||||||||||||||||||||||
Complete Diagnostic Approach
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[2]
Abbreviations: AF: atrial fibrillation; AVRT: AV reentrant tachycardia; BP: blood pressure; ECG: electrocardiography; HF: heart failure; LVH: left ventricular hypertrophy
Characterize the symptoms: ❑ Asymptomatic
❑ Duration
| |||||||||||||||||||||||||||
Identify possible triggers: ❑ Infection | |||||||||||||||||||||||||||
Examine the patient: Appearance of the patient Vitals
Cardiovascular | |||||||||||||||||||||||||||
Order studies: ❑ ECG | |||||||||||||||||||||||||||
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][3]
Does the patient have any of the following findings that require urgent cardioversion? ❑ Hemodynamic instability ❑ Chest discomfort suggestive of ischemia | |||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||
What is the type of tachycardia according to the ECG findings?
| |||||||||||||||||||||||||||||||
WPW+AF | Orthodromic AVRT | Antidromic AVRT | |||||||||||||||||||||||||||||
Avoid the use of AV node blocking agents such as digoxin, calcium channel blockers, beta blockers and adenosine.
Or
Or
| ❑ Use vagal maneuvers (Class I, Level of Evidence B)
If not effective
If not effective
| Avoid the use of AV node blocking agents such as digoxin, calcium channel blockers, beta blockers and adenosine.
Or
Or
| |||||||||||||||||||||||||||||
Long-Term Treatment
Shown below is an algorithm summarizing the long-term treatment of Wolff-Parkinson-White syndrome.[2]
Does the patient with pre-excitation have symptomatic arrhythmia? | |||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||
Is the arrhythmia poorly tolerated, OR is atrial fibrillation with rapid conduction present? | ❑ No treatment (Class I, Level of Evidence C) | ||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||
❑ Catheter ablation (Class I, Level of Evidence B) | |||||||||||||||||||||||||
Do's
- Perform catheter ablation of the accessory pathway if possible (Class I, Level of evidence B).
- Consider propafenone over flecainide for the prevention of recurrence of orthodromic AVRT because propafenone 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).
- Administer IV procainamide (Class I, Level of evidence C), ibutilide (Class I, Level of evidence C) or flecainide (Class IIa, Level of evidence B) among WPW syndrome patients who present with atrial fibrillation . Intravenous quinidine, procainamide, disopyramide, ibutilide, or amiodarone can also be considered (Class IIb, Level of evidence B).[5]
Don'ts
- Don't use AV blocking agents in patients with WPW and antidromic AVRT as it will promote conduction down the accessory pathway (Class III, Level of evidence C).[6][7][8]
- 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) in the chronic treatment of WPW syndrome 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 2.4 "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.
- ↑ 3.0 3.1 "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.
- ↑ 5.0 5.1 5.2 5.3 American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB; et al. (2013). "Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines". Circulation. 127 (18): 1916–26. doi:10.1161/CIR.0b013e318290826d. PMID 23545139.
- ↑ 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)