Wolff-Parkinson-White syndrome risk stratification
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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
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.
A good history should be taken to determine whether an individual has factors suggestive of a previous episode of unexplained syncope (fainting) orpalpitations (sudden awareness of one's own, usually irregular, heartbeat). These may be due to earlier episodes of a tachycardia associated with the accessory pathway.
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.[1]
It is unclear whether invasive risk stratification (with programmed electrical stimulation) is necessary in the asymptomatic individual.[2] 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 tachyarrhythmia, since the incidence of sudden death is so low.
Shown below is an EKG demonstrating WPW syndrome. The accessory pathway is located in the left posteroseptal region.]]
References
- ↑ Pappone C, Santinelli V, Manguso F, Augello G, Santinelli O, Vicedomini G, Gulletta S, Mazzone P, Tortoriello V, Pappone A, Dicandia C, Rosanio S. (2003). "A randomized study of prophylactic catheter ablation in asymptomatic patients with the Wolff-Parkinson-White syndrome" (free registration required). New England Journal of Medicine. 349 (19): 1803–11. PMID 14602878.
- ↑ Campbell RM, Strieper MJ, Frias PA, Collins KK, Van Hare GF, Dubin AM (2003). "Survey of current practice of pediatric electrophysiologists for asymptomatic Wolff-Parkinson-White syndrome". Pediatrics. 111 (3): e245–7. PMID 12612279.