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| {| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
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| ! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Wolff-Parkinson-White Syndrome Resident Survival Guide Microchapters}}
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Sandbox2#Overview|Overview]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Sandbox2#Causes|Causes]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Sandbox2#Diagnosis|Diagnosis]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Sandbox2#Management|Management]]
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| :[[Sandbox2#Long-term Management|Long-term Management]]
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| :[[Sandbox2#Wolff-Parkinson-White syndrome with Atrial fibrillation|WPW with AF]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Sandbox2#Do's|Do's]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Sandbox2#Don'ts|Don'ts]]
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| |}
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| == Overview==
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| [[Wolff-Parkinson-White syndrome]] (WPW) is a syndrome of pre-excitation of the [[Ventricle (heart)|ventricles]] of the [[heart]] due to an [[accessory pathway]] known as the [[Bundle of Kent]]. The diagnosis is made when a patient with pre-existing [[WPW]] patern in the ECG, developes an arrythmia which involves an accessory pathway. The treatment is focused on recovering sinus rythm. [[Atrial Fibrillation]] in a patient with [[WPW]] is lifethretening and should be managed urgently.
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| ==Causes==
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| ===Life Threatening Causes===
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| Life-threatening causes include conditions which result in death or permanent disability within 24 hours if left untreated. [[Wolff-Parkinson-White syndrome]] can be a life-threatening condition and must be treated as such irrespective of the underlying cause.
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| *[[Atrial fibrillation]]
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| ===Common Causes===
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| [[WPW]] is a congenic disease
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| ==Diagnosis==
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| 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.<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>
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| '''AVRT''': [[AV reentrant tachycardia]]
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| {{familytree/start}}
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| {{familytree | | | | A01 | | A01=<div style="float: left; text-align: left; width: 27em; padding:1em;"> '''Characterize the symptoms:'''<br>
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| ❑ Asymptomatic <br>
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| ❑ [[Palpitations]]<br>
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| ❑ [[Dyspnea]] <br>
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| ❑ [[Fatigue]] <br>
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| ❑ [[Chest pain|Chest discomfort]] <br>
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| ❑ [[Lightheadedness]] <br>
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| ❑ [[Polyuria]] <br>
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| '''Characterize the timing of the symptoms:'''<br>
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| ❑ Onset <br>
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| ❑ Duration <br>
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| ❑ Frequency
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| </div> }}
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| {{familytree | | | | |!| | | }}
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| {{familytree | | | | B01 | | | B01= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Identify possible triggers:'''<br>
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| ❑ [[Infection]]<br>
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| ❑ [[Caffeine]]<br>
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| ❑ [[Alcohol]]<br>
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| ❑ [[Nicotine]]<br>
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| ❑ [[Congenital heart disease]]<br>
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| ❑ [[Congestive heart failure]] <br>
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| ❑ [[Valvular disease]]<br>
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| ❑ [[Hypovolemia]]<br>
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| ❑ [[Acidosis]] <br>
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| ❑ [[Hyperthyroidism]]<br>
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| ❑ [[Hypoxia]]<br>
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| ❑ [[Anxiety]] <br>
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| ❑ [[Hypokalemia]]<br>
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| ❑ [[Hyperkalemia]]<br>
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| ❑ [[Hypoglycemia]] <br>
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| ❑ [[Hypothermia]]<br>
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| ❑ [[Toxins]]<br>
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| ❑ [[Stress]] <br>
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| ❑ [[Pulmonary embolism]]<br>
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| ❑ [[Coronary thrombosis]]<br>
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| ❑ [[Trauma]] <br>
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| </div>}}
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| {{familytree | | | | |!| | | }}
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| {{familytree | | | | C01 | | | C01= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Examine the patient:'''<br>
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| ❑ Patient may apear cool and diaphoretic <br>
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| '''Vitals''' <br>
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| ❑ [[Heart rate]]: symptomatic patients usually present with heart rates between 150-250 beats per minute (bpm)<br>
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| ❑ [[Blood pressure]]: patient may be hypotensive<br>
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| '''Cardiovascular'''<br>
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| ❑ Normal heart examination in most cases <br>
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| '''Respiratory'''<br>
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| ❑ Search for [[Rales|crackles]]
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| </div>}}
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| {{familytree | | | | |!| | | }}
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| {{familytree | | | | C01 | | | C01= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Order studies:'''<br>
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| ❑ [[ECG]] <br>
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| ❑ [[Echocardiography]] to evaluate cardiac function and dimentions, search for assciated conditions such as: <br>
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| :❑ [[Hypertrophic cardiomyopathy]]
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| :❑ [[Ebstein's anomaly of the tricuspid valve]]
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| </div>}}
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| {{familytree | |,|-|-|^|-|-|.| | | |}}
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| {{familytree | D01 | | | | D02 | | | | D01= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Orthodromic AVRT''' <br>
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| The impulse travels from the atrium to the ventricle through the AV node and returns to the atrium through the accessory pathway. 90-95% of [[WPW]]<br>
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| [[File:Orthodromic AVRT.png|200px|center]]<br>
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| '''[[EKG]] findings:''' <br>
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| ❑ Narrow QRS complexes <br>
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| ❑ Ventricular rate between 150-250 bpm (or more) usually regular <br>
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| ❑ PR interval less than one half of the tachycardia RR interval
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| </div>|
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| D02= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Antidromic AVRT''' <br>
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| The impulse travels from the atrium to the ventricle through the accessory pathway and from the ventricle to the atrium through the AV node. Less than 10% of [[WPW]]<br>
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| [[File:Antidromic AVRT.png|200px|center]] <br>
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| '''[[EKG]] findings:''' <br>
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| ❑ Wide QRS complexes <br>
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| ❑ Ventricular rate between 150-250 bpm (or more) usually regular <br>
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| ❑ PR interval more than one half of the tachycardia RR interval
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| </div> }}
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| {{familytree/end}}
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|
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| ==Management==
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| 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.<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>
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| {{familytree/start}}
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| {{familytree | | | | | | A01 | | | A01= <div style="float: left; text-align: left; width: 24em; padding:1em;">'''Initial approach'''<br>
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| ❑ Determine [[blood pressure]] <br>
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| ❑ Determine [[heart rate]] <br>
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| </div>}}
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| {{familytree | | | |,|-|-|^|-|-|.| | | | |}}
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| {{familytree | | | D01 | | | | D02 | | | | D01= '''Stable patient'''| D02= '''Unstable patient'''}}
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| {{familytree | | | |!| | | | | |!| | | | }}
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| {{familytree | | | E01 | | | | E02 | | | | E01= <div style="float: left; text-align: left"> ❑ Assess the [[ECG]] </div>|
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| E02= <div style="float: left; text-align: left; width: 24em"><br>
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| ❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|class I, level of evidence B]])<br>
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| ❑ Urgent electrical [[cardioversion]] ([[ACC AHA guidelines classification scheme|class I, level of evidence C]])<br>
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| </div>}}
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| {{familytree | |,|-|^|-|.| | | | | }}
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| {{familytree | F01 | | F02 | | | | | F01= '''Orthodromic AVRT'''| F02= '''Antidromic AVRT'''}}
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| {{familytree | |!| | | |!| | | | | |}}
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| {{familytree | G01 | | G02 | | | | G01= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Treatment'''<br>
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| ❑ Use [[vagal maneuvers]] ([[ACC AHA guidelines classification scheme|class I, level of evidence B]])<br>
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| :❑ [[Carotid sinus massage]] <br>
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| :❑ [[Valsalva maneuver]] <br>
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| <br>''If not effective initiate IV AV nodal blocking agent''<br><br>
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| ❑ Administer [[adenosine]], 6 mg (initial dose) that could be followed by 12 mg if initial dose not effective <br>
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| :❑ Administer IV followed by 10 cc of saline solution ([[ACC AHA guidelines classification scheme|class I, level of evidence A]])<br>
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| :<span style="font-size:85%;color:red">Contraindications: second- or third-degree A-V block, sinus node disease</span><br>
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| <br>''If not effective''<br><br>
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| ❑ Administer [[verapamil]], given in boluses of 5 mg every two to three minutes up to cumulative 15 mg ([[ACC AHA guidelines classification scheme|class I, level of evidence A]])<br>
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| :❑ Additional ECG monitoring should be perforemed in patients with renal insufficiency<br>
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| :❑ In cirrhosis, reduce dose to 20% and 50% of normal<br>
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| :<span style="font-size:85%;color:red">Contraindications: hypotension (systolic pressure less than 90 mm Hg) or cardiogenic shock, patients with known hypersensitivity to verapamil hydrochloride</span><br>
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| <br>''If not effective''<br><br>
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| ❑ Administer [[procainamide]], give intravenusly 20 to 50 mg/minute until the arrythmia is controlled or reach 17 mg/kg.<br>
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| :❑ Must monitor blood pressure every 5 to 10 minnutes ([[ACC AHA guidelines classification scheme|class I, level of evidence B]]) <br>
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| :❑ Reduce the loading dose to 12 mg/kg in severe renal impairment<br>
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| :❑ Reduce the dosage to 50% in hepatic impaiment<br>
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| :<span style="font-size:85%;color:red">Contraindications: complete heart block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes</span><br>
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| </div> |
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| G02= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Treatment'''<br>
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| ❑ Administer:
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| :❑ [[ibutilide]] is the prefered treatment, 1 mg in an infusion over 10 minutes ([[ACC AHA guidelines classification scheme|class I, level of evidence B]])<br>
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| ::❑ If the tachycardia is not controlled give another 1 mg infusion over 10 minutes <br>
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| ::<span style="font-size:85%;color:red">Contraindications: hypersensitivity to ibutilide or any component of the formulation, QTc >440 msec</span><br>
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| <br>''Or''<br><br>
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| :❑ [[procainamide]] <br> 20 to 50 mg/minute until the arrythmia is controlled or reach 17 mg/kg ([[ACC AHA guidelines classification scheme|class I, level of evidence B]])<br>
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| ::❑ Must monitor blood pressure every 5 to 10 minnutes <br>
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| ::❑ Reduce the loading dose to 12 mg/kg in severe renal impairment<br>
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| ::❑ Reduce the dosage to 50% in hepatic impaiment <br>
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| ::<span style="font-size:85%;color:red">Contraindications: complete heart block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes</span><br>
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| ❑ [[adenosine]] should be used with caution because may produce [[AF]]<br>
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| :❑ Administer 6 mg (initial dose) that could be followed by 12 mg if initial dose not effective<br>
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| :❑ Administer IV followed by 10 cc of saline solution<br>
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| :<span style="font-size:85%;color:red">Contraindications: second- or third-degree A-V block, sinus node disease</span><br>
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| </div>}}
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| {{familytree/end}}
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|
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|
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| ===Long-term Management===
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|
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| {{familytree/start}} | | {{familytree/start}} |
| {{familytree | | | | | | A01 | | | | | A01= '''Long term management'''}} | | {{familytree | | | | | | | A01 | | | | | | |A01=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Identify cardinal symptoms and signs that increase the pre-test probability of palpitations'''<br> |
| {{familytree | |,|-|-|-|-|+|-|-|-|-|-|-|.| | |}} | | Symprtoms:<br> |
| {{familytree | B01 | | | B02 | | | | | B03 | | B01= <div style="float: left; text-align: left; width: 24em; padding:1em;"> ''' Single or infrequent episodes'''<br> | | ❑ Flip-flopping of the chest<br> |
| ❑ No treatment ([[ACC AHA guidelines classification scheme|class I, level of evidence C]]) <br> | | ❑ Rapid fluttering of the chest<br> |
| ❑ [[Vagal maneuvers]] ([[ACC AHA guidelines classification scheme|class I, level of evidence B]]) <br> | | ❑ Pounding in the neck<br> |
| ❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|class IIa, level of evidence B]]) <br> | | ❑ Pulsation palpitations <br> |
| ❑ Avoid the use of [[digoxin]] ([[ACC AHA guidelines classification scheme|class III, level of evidence C]]) | | Signs:<br> |
| </div> | | | ❑ Increased heart rate with regular or irregular rhythm<br> |
| B02= <div style=" float: left; text-align: left; width: 24em; padding: 1em;"> ''' Prevention of recurrent AVRT''' <br> | | ❑ Cardiological findings suggestive of a cardiological disease<br> |
| </div> | | | : ❑ [[Murmurs]]<br> |
| B03= <div style="float: left; text-align: left; width: 24em; padding:1em;"> ''' Asymptomatic''' <br> | | : ❑ [[S3]] sound<br> |
| ❑ No treatment ([[ACC AHA guidelines classification scheme|class I, level of evidence C]]) <br> | | : ❑ [[Muffled heart sounds]]<br> |
| ❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|class IIa, level of evidence B]]) <br> | | : ❑ Displaced [[apex beat]]</div>}} |
| </div>}} | | {{familytree | | | | | | | |!| | | | | | |}} |
| {{familytree | | | |,|-|-|^|-|-|.| | | | | |}} | | {{familytree | | | | | | | B01 | | | | | | |B01=<div style="float: left; text-align: left; width: 16em; padding:1em;">''' Does the patient have any of the followign findings that require urgent management?'''<br> |
| {{familytree | | | C01 | | | | C02 | | | | | C01= <div style="float: left; text-align: left; width: 24em; padding:1em;"> ''' Orthodromic AVRT'''<br> | | ❑ Palpitations asociated with [[syncope]] (suggestive of [[VT]] of [[structural heart disease]]) |
| ❑ [[Antiarrhythmic agent|class IC antiarrhythmic drugs]] such as [[flecainide]] and [[propofenone]] <br>
| | ❑ [[Chest discomfort]] suggestive of [[ischemia]]<br> |
| ❑ [[Beta blockers]] are used as second-line therapy<br>
| | ❑ Decompensated [[heart failure]]<br> |
| ❑ [[Antiarrhythmic agent|class IA antiarrhythmic drugs]] such as [[procainamide]] and [[quinidine]] can be used but are less efective than [[Antiarrythmic agent|class IC antiarrhythmic drugs]]<br>
| | ---- |
| ❑ [[Amiodarone]] is very efective in supresing orthodromic AVRT, but has too many adverse efects such as: pulmonary and hepatic toxicity.
| | ❑ Consider [[Cardioversion|electrical cardioversion]]</div>}} |
| ❑ Avoid the chronic treatment with [[verapamil]] or [[digoxin]]<br>
| | {{familytree | | | | |,|-|-|^|-|-|.| | |}} |
| </div> |
| | {{familytree | | | | W01 | | | | W02 | | | | |W01='''Yes'''|W02='''No'''}} |
| C02= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Antidromic AVRT'''< br> | | {{familytree | | | | |!| | | | | |!| | }} |
| ❑ [[Catheter ablation]] is the prefered therapy <br>
| | {{familytree | | | | Y01 | | | | Y02 | | | | Y01='''Does the patient have any of the following findings suggesting of hemodynamic instability?'''|Y02='''[[SandboxAlonso#Complete diagnostic approach|Continue with the complete duagnostic apporoach shown below]]'''}} |
| ❑ Medical therapy: reserved to patients who are not candidates or feeruse to the intervention.
| | ❑ [[Hemodynamic instability]]<br> |
| :❑ [[Antiarrhythmic agent|class IC antiarrhythmic drugs]] such as [[flecainide]] and [[propofenone]] <br>
| | ❑ [[Hypotension]]<br> |
| :❑ [[Antiarrythmic agent|class IA antiarrhythmic drugs]] such as [[procainamide]] and [[quinidine]] can be used but are less efective than [[Antiarrythmic agents|class IC antiarithmic drugs]]<br>
| | ❑ [[Cold extremities]]<br> |
| :❑ [[Amiodarone]] is also efective, but it should be reserved for patients who doesn't respond to [[Antiarrhythmic agent|class IC antiarrhythmic drugs]] and [[Antiarrythmic agent|class IA antiarrhythmic drugs]], or catheter ablation was ineffective. <br>
| | ❑ [[Cyanosis|Peripheral cyanosis]]<br> |
| </div>}}
| | ❑ [[Mottling]]<br> |
| {{familytree/end}}
| | ❑ [[Altered mental status]]<br> |
| | | {{familytree | | | | | |,|-|^|-|.| | | |}} |
| ===Wolff-Parkinson-White syndrome with atrial fibrillation===
| | {{familytree | | | | | | C01 | | C02 | | | |C01={{fontcolor|#F8F8FF|'''Yes'''}}|C02=<div style="text-align: center; background: #FFFFFF; height: 25px; line-height: 25px;">''' No'''</div> }} |
| 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.<ref name="Fuster-2006">{{Cite journal | last1 = Fuster | first1 = V. | last2 = Rydén | first2 = LE. | last3 = Cannom | first3 = DS. | last4 = Crijns | first4 = HJ. | last5 = Curtis | first5 = AB. | last6 = Ellenbogen | first6 = KA. | last7 = Halperin | first7 = JL. | last8 = Le Heuzey | first8 = JY. | last9 = Kay | first9 = GN. | title = 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. | journal = Circulation | volume = 114 | issue = 7 | pages = e257-354 | month = Aug | year = 2006 | doi = 10.1161/CIRCULATIONAHA.106.177292 | PMID = 16908781 }}</ref>
| | {{Familytree | | | | | |!| | | |!| | | |}} |
| | {{familytree | | | | | |!| | | D01 | | | |D01=}} |
| | {{familytree | | | | | | E01 | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 14em; padding:1em ; color: #FFFFFF;">''' Stabilize the patient'''<br> |
| | ❑ Assess circulation, secure airway and breathing<br> |
| | ❑ Secure IV line<br> |
| | ❑ Offer [[Oxygen therapy|<span style="color:white;">oxygen</span>]]<br> |
| | ❑ Cardiac monitor to identify rhythm<br> |
| | ❑ Monitor [[Blood pressure|<span style="color:white;">blood pressure</span>]] and [[Pulse oximeter|<span style="color:white;">oximetry</span>]]</div>}} |
| | {{familytree | | | | | |!| | | | | | | | }} |
| | {{familytree | | | | | | F01 | | | | | | | | | F01=<div style="float: left; text-align: center; width: 14em; padding:1em ; color: #FFFFFF;">''' Order and EKG immediately'''<br><br> |
| | Does the patient has any EKG findings suggestive of an arrhythmia?</div>}} |
| | {{familytree | | | |,|-|^|-|.| | | }} |
| | {{familytree | | | | G01 | | G02 | | | | |G01={{fontcolor|#F8F8FF|'''Yes'''}}|G02={{fontcolor|#F8F8FF|'''No'''}}}} |
| | {{familytree | | | |!| | | |!| | | |}} |
| | {{familytree | | | | H01 | | |!| | | | |H01=<div style="float: left; text-align: left; width: 14em; padding:1em;"> [[Narrow complex tachycardia#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Narrow complex tachycardia< /span>]]<br> [[ Wide complex tachycardia#FIRE: Focused Initial Rapid Evaluation| <span style="color:white;">Wide complex tachycardia</span>]]<br> [[ Bradycardia#FIRE: Focused Initial Rapid Evaluation|< span style="color:white;">Bradycardia</span>]]<br> [[Wolff-Parkinson-White syndrome resident survival guide#FIRE: Focused Initial Rapid Evaluation|< span style=" color:white;"> WPW</span>]]</div>}} |
| | {{familytree | | | | | | | | Z02 | | | | | | | | |Z02=<div style="float: left; text-align: left; width: 24em; padding:1em; color: #FFFFFF;">'''Does the patient have any EKG findings suggestive of myocardial ischemia or pericarditis?'''<br> |
|
| |
|
| {{familytree/start}}
| | [[STEMI resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">STEMI</span>]]<br> |
| {{familytree | | | | A01 | | | | | | | | | A01=<div style="float: left; text-align: left; width: 27em; padding:1em;"> '''Initial approach'''<br>
| | ❑ [[ST elevation|<span style="color:white;">ST elevation</span>]] in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads<br> |
| ❑ Control ventricular response<br>
| | ❑ [[ST depression|<span style="color:white;">ST depression</span>]] in at least two precordial leads V1-V4 (suggestive of [[posterior myocardial infarction|<span style="color:white;">posterior MI</span>]])<br> |
| ❑ If possible: terminate [[AF]]<br> | | ❑ [[ST depression|<span style="color:white;">ST depression</span>]] in several leads plus [[ST elevation|<span style="color:white;">ST elevation</span>]] in lead aVR (suggestive of occlusion of the [[left main|<span style="color:white;">left main</span>]] or proximal [[LAD|<span style="color:white;">LAD</span>]] artery)<br> |
| ❑ If possible: catheter ablation of the accessory pathway ([[ACC AHA guidelines classification scheme|class I, level of evidence B]])<br> | | ❑ New [[LBBB|<span style="color:white;">LBBB</span>]]<br> |
| </div>}} | | ---- |
| {{familytree | |,|-|-|^|-|-|.| |}}
| | NSTEMI:<br> |
| {{familytree | B01 | | | | B02 | B01='''Stable patient'''| B02='''Unstable patient'''}}
| | ❑ [[Non specific ST / T wave changes|<span style="color:white;">Non specific ST / T wave changes</span>]]<br> |
| {{familytree | |!| | | | | |!| | | | |}}
| | ❑ Flipped or inverted [[T wave|<span style="color:white;">T waves</span>]]<br> |
| {{familytree | C01 | | | | C02 | | | | C01= <div style="float: left; text-align: left; width: 27em; padding:1em;">
| | ❑ [[Electrocardiogram|<span style="color:white;">ST Depression</span>]]<br> |
| ❑ Restore sinus rythm ([[ACC AHA guidelines classification scheme|class I, level of evidence C]])<br>
| | ---- |
| :❑ [[Ibutilide]] administer 1 mg in an infusion over 10 minutes, if the tachycardia is not controlled give another 1 mg infusion over 10 minutes ([[ACC AHA guidelines classification scheme|class I, level of evidence C]])<br>
| | [[Pericarditis resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Pericarditis</span>]]<br> |
| ::<span style="font-size:85%;color:red">Contraindications: hypersensitivity to ibutilide or any component of the formulation, QTc >440 msec</span><br>
| | ❑ [[ST segment elevation|<span style="color:white;">ST segment elevation</span>]] in leads I, II, aVL, aVF, and V3-V6<br> |
| <br>''Or''<br><br> | | ❑ [[PR segment depression|<span style="color:white;">PR segment depression</span>]]<br> |
| :❑ [[Procainamide]] administer 20 to 50 mg/minute until the arrythmia is controlled or reach 17 mg/kg ([[ACC AHA guidelines classification scheme|class I, level of evidence B]])<br>
| | ❑ [[Low QRS voltage|<span style="color:white;">Low QRS voltage</span>]] (in large [[Pericardial effusion|<span style="color:white;">pericardial effusion</span>]] and [[Constrictive pericarditis|<span style="color:white;">constrictive pericarditis</span>]])<br> |
| ::❑ Must monitor blood pressure every 5 to 10 minnutes <br>
| | ❑ [[Cardiac tamponade|<span style="color:white;">Cardiac tamponade</span>]]: [[Electrical alternans|<span style="color:white;">electrical alternans</span>]]<br> |
| ::❑ Reduce the loading dose to 12 mg/kg in severe renal impairment<br>
| |
| ::❑ Reduce the dosage to 50% in hepatic impaiment <br> | |
| ::<span style="font-size:85%;color:red">Contraindications: complete heart block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes</span><br>
| |
| <br>''Or''<br><br> | |
| :❑ [[Amiodarone]], administer 5-7 mg/kg over 30-60 minutes (initial dose), then 1.2-1.8 g daily continuous infusion or in divided oral doses until 10 g total ([[ACC AHA guidelines classification scheme|class IIb, level of evidence B]])<br>
| |
| ::<span style="font-size:85%;color:red">Contraindications: cardiogenic shock, severe sinus-node dysfunction</span><br>
| |
| ❑ Avoid AV blocking agents ([[ACC AHA guidelines classification scheme|class III, level of evidence B]]), such as:<br> | |
| :❑ [[Digoxin]]
| |
| :❑ [[Nondihydropyridine calcium channel antagonists]]: [[verapamil]], [[diltizem]]<br>
| |
| </div> | | |
| 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]])<br>
| |
| ❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|class I, level of evidence B]])<br> | |
| </div>}} | | </div>}} |
| | {{familytree | | | | |,|-|-|^|-|-|.| |}} |
| | {{familytree | | | | | I01 | | | | I02 | | | |I01={{fontcolor|#F8F8FF|'''Yes'''}}|I02={{fontcolor|#F8F8FF|'''No'''}}}} |
| | {{familytree | | |,|-|^|-|.| | | |!| | | |}} |
| | {{familytree | | | J01 | | J02 | | J03 | | | | |J01=[[STEMI resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">STEMI</span>]]<br> [[Unstable angina/ NSTEMI resident survival guide#Treatment approach|<span style="color:white;">NSTEMI</span>]]<br>|J02=[[Pericarditis resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Pericarditis</span>]]|J03=<div style="float: left; text-align: left; width: 14em; padding:1em; color: #FFFFFF;">Order a [[Echocardiography|<span style="color:white;">TTE</span>]]</div>}} |
| | {{familytree | | | | | | | | | | |!| | | | | |}} |
| | {{familytree | | | | | | | | | | | K01 | | |K01=<div style="float: left; text-align: center; width: 18em; padding:1em; color: #FFFFFF;">'''Does the patient have any structural heart disease?'''</div>}} |
| | {{familytree | | | | | | | | |,|-|^|-|.| | | |}} |
| | {{familytree | | | | | | | | | L01 | | L02 | | |L01={{fontcolor|#F8F8FF|'''Yes'''}}|L02={{fontcolor|#F8F8FF|'''No'''}}}} |
| | {{familytree | | | | | | | | |!| | | |!| | | |}} |
| | {{familytree | | | | | | | | | M01 | | M02 | | | | |M01=[[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Acute heart failure</span>]]<br> [[Aortic stenosis resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">AS</span>]]<br> [[Aortic regurgitarion resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Acute AR</span>]]<br>|M02=<div style="float: left; text-align: center; width: 22em; padding:1em; color: #FFFFFF;">'''Does the patient have history of consuming any toxic substance that can explain the palpitations and hemodynamic instability?'''</div>}} |
| | {{familytree | | | | | | | | | | |,|-|^|-|.| | | |}} |
| | {{familytree | | | | | | | | | | | N01 | | N02 | | | |N01={{fontcolor|#F8F8FF|'''Yes'''}}|N02={{fontcolor|#F8F8FF|'''No'''}}}} |
| | {{familytree | | | | | | | | | | |!| | | |!| | | | |}} |
| | {{familytree | | | | | | | | | | | O01 | | O02 | | | |O01=<div style="float: left; text-align: left; width: 14em; padding:1em;">[[Alcohol|<span style="color:white;">Alcohol</span>]]<br> [[Cocaine|<span style="color:white;">Cocaine</span>]]<br> [[Heroin|<span style="color:white;">Heroin</span>]]<br> [[Amphetamines|<span style="color:white;">Amphetamines</span>]]</div>|O02=<div style="float: left; text-align: center; width: 14em; padding:1em; color: #FFFFFF;">Look for systemic diseases than can cause palpitations and hemodynamic instability</div>}} |
| | {{familytree | | | | | | | | | | | | | | |!| | | | | |}} |
| | {{familytree | | | | | | | | | | | | | | | P01 | | | | | |P01=[[Electrolyte disturbance#ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT)|<span style="color:white;">Electrolyte disturbances</span>]]<br>[[Hyperthyroidism medical therapy|<span style="color:white;">Hyperthyroidism</span>]]<br>[[Hypoglycemia medical therapy|<span style="color:white;">Hypoglycemia</span>]]<br>[[Hypovolemia#Treatment|<span style="color:white;">Hypovolemia</span>]]<br>}} |
| {{familytree/end}} | | {{familytree/end}} |
|
| |
| ==Do's==
| |
| ❑ Perform [[catheter ablation]] of the accessory pathway if possible ([[ACC AHA guidelines classification scheme|class I, level of evidence B]]). <br>
| |
| ❑ Electrical [[cardioversion]] can be performed in cases of [[WPW]] with [[AF]] with rapid ventricular response ([[ACC AHA guidelines classification scheme|class II, level of evidence A]]).<br>
| |
| ❑ In asymptomatic patients, either no intervantion ([[ACC AHA guidelines classification scheme|class I, level of evidence C]]) or [[catheter ablation]] ([[ACC AHA guidelines classification scheme|class IIb, level of evidence B]]) could be performed.<br>
| |
| ❑ Prescribe [[propofenone]] over [[flecainide]] for the prevention of recurrence orthodromic AVRT as it has also a mild beta blocking activity. <br>
| |
| ❑ Schedule [[exccercise stress test]] and [[electrophysiology]] tests for the sudden cardiac death stratification ([[ACC AHA guidelines classification scheme|class IIa, level of evidence B]]). <br>
| |
| ❑ Consider [[catheter ablation]] in asymptomatic patients with structural heart disease ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]])<br>
| |
|
| |
| ==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 ([[ACC AHA guidelines classification scheme|class III, level of evidence C]]).<ref name="Garratt-1989">{{Cite journal | last1 = Garratt | first1 = C. | last2 = Antoniou | first2 = A. | last3 = Ward | first3 = D. | last4 = Camm | first4 = AJ. | title = Misuse of verapamil in pre-excited atrial fibrillation. | journal = Lancet | volume = 1 | issue = 8634 | pages = 367-9 | month = Feb | year = 1989 | doi = | PMID = 2563516 }}</ref>
| |
| <ref name="Gulamhusein-1982">{{Cite journal | last1 = Gulamhusein | first1 = S. | last2 = Ko | first2 = P. | last3 = Carruthers | first3 = SG. | last4 = Klein | first4 = GJ. | title = Acceleration of the ventricular response during atrial fibrillation in the Wolff-Parkinson-White syndrome after verapamil. | journal = Circulation | volume = 65 | issue = 2 | pages = 348-54 | month = Feb | year = 1982 | doi = | PMID = 7053894 }}</ref>
| |
| <ref name="McGovern-1986">{{Cite journal | last1 = McGovern | first1 = B. | last2 = Garan | first2 = H. | last3 = Ruskin | first3 = JN. | title = Precipitation of cardiac arrest by verapamil in patients with Wolff-Parkinson-White syndrome. | journal = Ann Intern Med | volume = 104 | issue = 6 | pages = 791-4 | month = Jun | year = 1986 | doi = | PMID = 3706931 }}</ref><br>
| |
| ❑ Avoid the usage of AV blocking agents in patients with [[WPW]] and [[AF]] ([[ACC AHA guidelines classification scheme|class III, level of evidence B]]).<br>
| |
|
| |
| ==References==
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|
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| {{reflist|1}}
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