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==Risk Stratification==
==Risk Stratification==
A good history should be taken to determine whether an individual has factors suggestive of a previous episode of unexplained [[syncope]] (fainting) or [[palpitations]] (sudden awareness of one's own, usually irregular, heartbeat).  These may be due to earlier episodes of a tachycardia associated with the accessory pathway.
:*Low-risk patients for life-threatening arrhythmia over the [[accessory pathway]] during [[AF]] include the following:
*Abrupt loss of conduction over the pathway during [[ exercise test]] in [[sinus rhythm]]
*Intermittent loss of preexcitation during EKG or ambulatory monitoring
 
 
 
:*High-risk patients for life-threatening arrhythmia in the [[electrophysiologic study]] include the following:
 
* R-R<250 ms between two pre-excited complexes during induced [[ AF]]
* The presence of multiple [[accessory pathways]]
* the finding of [[AVRT]] precipitating pre-excited [[AF]]
 
 
ofabruptlossofconductionoverthe
pathway duringexercisetestinginsinusrhythm294–297 (Level ofEvidence:B-NR) or intermittentloss
of pre-excitationduringECGorambulatorymonitoring297 (Level ofEvidence:C-LD) are usefulfor
identifying patientsatlowriskofdevelopingrapidconductionoverthepathway
 
areanR-Rinterval o250 msbetween2pre-excitedcomplexes
during inducedAF;thepresenceofmultipleaccessorypathways;the finding ofAVRTprecipitating
pre-excited AF;andanaccessorypathwayrefractoryperiod o240 ms
 
 
 


Individuals with WPW syndrome in whom the delta waves disappear with increases in the heart rate are considered at lower risk of SCD.  This is because the loss of the delta wave shows that the accessory pathway cannot conduct electrical impulses at a high rate (in the anterograde direction).  These individuals will typically not have fast conduction down the accessory pathway during episodes of atrial fibrillation.


Risk stratification is best performed via [[programmed electrical stimulation]] (PES) in the [[cardiac electrophysiology]] lab.  This is an invasive procedure, in which the rate of impulse propagation via the accessory pathway is determined by stimulating the atria and by inducing transient [[atrial fibrillation]].


High risk features that may be present during PES include an effective refractory period of the accessory pathway less than 270 ms, multiple pathways, septal location of pathway, and inducibility of supraventricular tachycardia.  Individuals with any of these high risk features are generally considered at increased risk for SCD and should be treated accordingly.<ref name = Pappone_et_al_2003>{{cite journal
| author=Pappone C, Santinelli V, Manguso F, Augello G, Santinelli O, Vicedomini G, Gulletta S, Mazzone P, Tortoriello V, Pappone A, Dicandia C, Rosanio S.
| title=A randomized study of prophylactic catheter ablation in asymptomatic patients with the Wolff-Parkinson-White syndrome
| journal=New England Journal of Medicine
| volume=349
| issue=19
| year=2003
| pages=1803-11
| id=PMID 14602878
| url = http://content.nejm.org/cgi/content/full/349/19/1803
| format = free registration required }}</ref>


It is unclear whether invasive risk stratification (with programmed electrical stimulation) is necessary in the asymptomatic individual.<ref name =Cambell_et_al_2003>{{cite journal
| author=Campbell RM, Strieper MJ, Frias PA, Collins KK, Van Hare GF, Dubin AM
| title=Survey of current practice of pediatric electrophysiologists for asymptomatic Wolff-Parkinson-White syndrome
| journal=Pediatrics
| volume=111| issue=3| year=2003| pages=e245-7
| id=PMID 12612279
| url = http://pediatrics.aappublications.org/cgi/content/full/111/3/e245
}}</ref>  While some groups advocate PES for risk stratification in all individuals under 35 years old, others only offer it to individuals who have history suggestive of a [[tachycardia|tachyarrhythmia]], since the incidence of sudden death is so low.


==References==
==References==

Revision as of 09:08, 15 September 2020

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

Overview

Treatment is based on risk stratification of the individual. Risk stratification is performed to determine which individuals with WPW syndrome are at risk for sudden cardiac death (SCD). Sudden cardiac death in these individuals is due to the propagation of an atrial arrhythmia to the ventricles at a very high rate.

Risk Stratification

  • Low-risk patients for life-threatening arrhythmia over the accessory pathway during AF include the following:
  • Abrupt loss of conduction over the pathway during exercise test in sinus rhythm
  • Intermittent loss of preexcitation during EKG or ambulatory monitoring


  • R-R<250 ms between two pre-excited complexes during induced AF
  • The presence of multiple accessory pathways
  • the finding of AVRT precipitating pre-excited AF


ofabruptlossofconductionoverthe pathway duringexercisetestinginsinusrhythm294–297 (Level ofEvidence:B-NR) or intermittentloss of pre-excitationduringECGorambulatorymonitoring297 (Level ofEvidence:C-LD) are usefulfor identifying patientsatlowriskofdevelopingrapidconductionoverthepathway

areanR-Rinterval o250 msbetween2pre-excitedcomplexes during inducedAF;thepresenceofmultipleaccessorypathways;the finding ofAVRTprecipitating pre-excited AF;andanaccessorypathwayrefractoryperiod o240 ms





References

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