Wolff-Parkinson-White syndrome EKG
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Wolff-Parkinson-White (WPW) pattern is characterized by ECG findings such as a short PR interval and a delta wave and wide QRS complex.[[ WPW syndrome] is the occurrence of tachycardia with or without associated symptoms in a subject with existing WPW pattern.[1] Several types of arrhythmia can occur in WPW syndrome such as AV reentrant tachycardia (AVRT), atrial fibrillation,or atrial flutter, the most common of which is AVRT.[2] WPW syndrome can present as an orthodromic or antidromic AVRT during which the delta wave no longer appears. Atrial fibrillation in a patient with WPW should be suspected when there is ECG findings of an irregularly irregular rhythm and absent P waves suggestive of atrial fibrillation in the context of a heart rate higher than 240 beats per minute.
WPW Pattern
- WPW pattern is characterized by the following typical EKG findings:
- Short PR interval: The PR interval is short because the ventricles begins to contract earlier than usual because of the electrical signal travels through the accessory pathway faster than the AV node.
- Wide QRS
- delta wave
- QRS alternans
- ST segment depression.
- Preexcitation and presence of delta waves typical of WPW syndrome or WPW pattern may either mimic myocardial infarction or may mask it.[3]
- Abolishment of delta waves may be necessary for the diagnosis of myocardial infarction on ECG.[4]
- Left posterolateral or lateral accessory pathways may mask inferior or anteroseptal myocardial infarction .[5]
- Posteroseptal accessory pathways may mask an anterior MI.[5]
- Right anteroseptal and anterolateral accessory pathways may mask inferior or anterolateral MI.[5]
- Abolishment of delta waves may be necessary for the diagnosis of myocardial infarction on ECG.[4]
Determining the location of the accessory pathway
Check lead V1 | |||||
Negative delta wave in V1 = right ventricle | Positive delta wave im V1= left ventricle | ||||
Negative delta wave and QRS in II, III, AVF | Left axis | Inferior axis | Negative delta wave and QRS in II, III, AVF | Isoelectric or negative delta I, AVL, V5, V6 | |
Posteroseptal | Right free wall | Anteroseptal | Posteroseptal | Lateral |
WPW Syndrome
- WPW syndrome is the occurrence of tachycardia with or without associated symptoms in a subject with existing WPW pattern.[6]
- Several types ofarrhythmia can occur in WPW syndrome such as AV reentrant tachycardia (AVRT), atrial fibrillation,or atrial flutter
the most common type of tachyarrhythmia is AVRT.[2]
Orthodromic AVRT
- In orthodromic AVRT, the anterograde conduction (from the atrium to the ventricle) passes through theAV node and the retrograde conduction (from the ventricle to the atrium) passes through the accessory pathway.
- Orthodromic AVRT occurs in approximately 90 to 95% of WPW.
The EKG findings include the following:
- Regular rhythm
- Narrow QRS complexes
- Retrograde P wave following the QRS complex
- Long RP, short PR tachycardia
![](/images/6/60/SVT.jpg)
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.
- The EKG findings may include the following:
- Regular rhythm
- Wide QRS complexes tachycardia
![](/images/d/d9/Wide_complex_tachy.jpg)
Atrial Fibrillation in WPW
- Atrial fibrillation in WPW syndrome is life-threatening because it might lead to ventricular tachycardia.
- The suggestive findings of [[antidromic AVRT] and rapid atrial fibrillation on the ECG may include the following:
- Irregularly irregular rhythm
- Absent of P wave
- Wide WRS
- Ventricular rate >240 beats per minute[7]
Shown below is an ECG depicting an irregularly irregular rhythm with wide QRS and absent P waves suggestive of atrial fibrillation in WPW syndrome.
Examples
Shown below is an EKG of Wolff-Parkinson-White syndrome demonstrating slurred upstroke of the QRS complex (>110 milli sec), resulting in a delta-wave (arrow). The EKG also shows a short PR interval.
![](/images/4/43/Rhythm_WPW.png)
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
Shown below is an EKG showing a slurred upstroke QRS complex which is best appreciated in the precordial leads and a PR interval of less than 120 ms (short PR interval) suggesting WPW syndrome.
![](/images/1/14/Wolf_Parkinson_White_syndrome.png)
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
Shown below is an EKG demonstrating a delta wave in leads V2, I, aVL, with wide QRS complexes and left axis deviation suggesting WPW syndrome.
![](/images/6/6f/WPW_syndrome_1.jpg)
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
Shown below is an EKG showing a short PR interval of less than 120 ms, delta waves in leads I, aVF, aVL and chest leads with wide QRS complexes indicating WPW syndrome.
![](/images/3/3f/WPW_syndrome_2.jpg)
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
- For more EKG examples of Wolff-Parkinson-White syndrome click Wolff-Parkinson-White syndrome EKG examples here.
References
- ↑ "Wolff-Parkinson-White Syndrome and Accessory Pathways". Retrieved 1 April 2014.
- ↑ 2.0 2.1 "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.
- ↑ Smolders L, Majidi M, Krucoff MW, Crijns HJ, Wellens HJ, Gorgels AP (2008). "Preexcitation and myocardial infarction: conditions with confusing electrocardiographic manifestations". J Electrocardiol. 41 (6): 679–82. doi:10.1016/j.jelectrocard.2008.05.005. PMID 18602643.
- ↑ Liu R, Chang Q (2013). "The diagnosis of myocardial infarction in the Wolff-Parkinson-White syndrome". Int J Cardiol. 167 (3): 1083–4. doi:10.1016/j.ijcard.2012.10.055. PMID 23157811.
- ↑ 5.0 5.1 5.2 Preminger MW, Callans DJ, Gottlieb CD, Marchlinski FE (1994). "Radiofrequency catheter ablation used to unmask infarction Q waves in Wolff-Parkinson-White syndrome". Am Heart J. 128 (5): 1040–2. PMID 7942468.
- ↑ "Wolff-Parkinson-White Syndrome and Accessory Pathways". Retrieved 1 April 2014.
- ↑ Klein, George J.; Bashore, Thomas M.; Sellers, T. D.; Pritchett, Edward L. C.; Smith, William M.; Gallagher, John J. (1979). "Ventricular Fibrillation in the Wolff-Parkinson-White Syndrome". New England Journal of Medicine. 301 (20): 1080–1085. doi:10.1056/NEJM197911153012003. ISSN 0028-4793.