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Updated: Dec 7 2021

Wolff-Parkinson-White (WPW) Syndrome

  • Snapshot
    • A 17-year-old girl presents to the emergency room with lightheadedness and palpitation. Her pulse is 250/min and she is hemodynamically stable. An electrocardiogram shows an antidromic atrioventricular reentrant tachycardia. She is given procainamide with a resolution of the arrhythmia. Now in sinus rhythm, she is found to have a widened QRS, delta wave, and shortened PR interval on the electrocardiogram.
  • Introduction
    • Clinical definition
      • a ventricular pre-excitation syndrome resulting in an aberrant conduction tract that bypasses the atrioventricular (AV) node
    • Associated conditions
      • Ebstein anomaly
      • hypertrophic cardiomyopathy
  • Epidemiology
    • Risk factors
      • family history
  • Etiology
    • Can be familial
    • Pathogenesis
      • ventricular pre-excitation results from an aberrant conduction tract from the atria to the ventricle, known as the bundle of Kent
        • this fast accessory tract bypasses the slowest-conducting AV node
        • ventricles then depolarize earlier than normal
        • this causes the classic delta wave and widened QRS
      • administration of calcium channel blockers or digoxin will worsen a supraventricular tachycardia (SVT) caused by WPW syndrome
        • calcium channel blockers and digoxin block conduction in the AV node and will force more conduction down the aberrant tract, worsening WPW syndrome
  • Presentation
    • Symptoms
      • can be asymptomatic
      • if symptomatic, patients will present with an arrhythmia
        • palpitations
        • lightheadedness
        • syncope
        • dizziness
        • chest pain
    • Physical exam
      • tachycardia
  • Studies
    • Electrocardiogram (ECG)
      • delta wave
      • short PR interval
      • widened QRS complex
      • may have supraventricular tachycardia if symptomatic
    • Making the diagnosis
      • based on clinical presentation and ECG
  • Differential
    • Myocardial infarction
      • distinguishing factor
        • ST elevation on ECG
    • Bundle branch block
      • distinguishing factor
        • widened and abnormal terminal portion of QRS portion on ECG
  • Treatment
    • Management approach
      • drugs that delay AV node conduction is typically contraindicated in these patients, unless patients have confirmed orthodromic AVRT
    • Medical
      • procainamide
        • indications
          • for patients who are hemodynamically stable
          • for patients with antidromic AVRT (wide QRS complexes) or atrial fibrillation due to WPW syndrome
      • adenosine or calcium channel blocker
        • indication
          • for patients with orthodromic AVRT (narrow QRS complexes)
    • Non-operative
      • electrical cardioversion
        • indication
          • for all patients who are hemodynamically unstable due to arrhythmia
      • radiofrequency catheter ablation
        • indication
          • long-term definitive therapy for patients with WPW syndrome
  • Complications
    • Sudden cardiac death
  • Prognosis
    • Can present with the following arrhythmias
      • atrioventricular reentrant tachycardia (AVRT)
        • most commonly as orthodromic AVRT
          • narrow QRS complexes (< 120 ms)
        • less commonly as (5%) antidromic AVRT
          • wide QRS complexes
      • atrial fibrillation
      • atrial flutter
      • ventricular tachycardia
      • ventricular fibrillation and sudden death
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