Updated: 12/10/2020

Wolff-Parkinson-White (WPW) Syndrome

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Snapshot
  • A 10-year-old boy presents to the pediatrician’s office for an electrocardiogram. His family history includes Wolff-Parkinson-White syndrome and sudden cardiac death. His parents are adamant about an electrocardiogram at this visit. Results show a widened QRS, a delta wave, and a shortened PR interval, confirming the diagnosis.
Introduction
  • Clinical definition
    • a ventricular pre-excitation syndrome resulting in an aberrant conduction tract that bypasses the atrioventricular (AV) node 
  • 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 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
      • these medications block conduction in the AV node and will force more conduction down the aberrant tract, worsening WPW syndrome
  • Associated conditions
    • Ebstein anomaly
    • hypertrophic cardiomyopathy
  • Prognosis
    • can present with
      • atrioventricular reentrant tachycardia (AVRT)
        • most commonly as orthodromic AVRT
          • narrow QRS complexes
        • less commonly as (5%) antidromic AVRT
          • wide QRS complexes (> 120 ms)
      • atrial fibrillation
      • atrial flutter
      • ventricular tachycardia
      • ventricular fibrillation and sudden death
Presentation
  • Symptoms
    • can be asymptomatic
    • if symptomatic, patients will present with
      • 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
  • 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 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

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(M1.CV.13.39) An 18-year-old male reports to his physician that he is having repeated episodes of a "racing heart beat". He believes these episodes are occurring completely at random. He is experiencing approximately 2 episodes each week, each lasting for only a few minutes. During the episodes he feels palpitations and shortness of breath, then nervous and uncomfortable, but these feelings resolve in a matter of minutes. He is otherwise well. Vital signs are as follows: T 98.8F, HR 60 bpm, BP 110/80 mmHg, RR 12. Included is a copy of his resting EKG. What is the likely diagnosis? Tested Concept

QID: 100555
FIGURES:
1

Paroxysmal atrial fibrillation

39%

(32/83)

2

Panic attacks

16%

(13/83)

3

Ventricular tachycardia

5%

(4/83)

4

Atrioventricular reentrant tachycardia

35%

(29/83)

5

Atrioventricular block, Mobitz Type II

4%

(3/83)

M 2 C

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