Wolff-Parkinson-White syndrome EKG: Difference between revisions

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{{Wolff-Parkinson-White syndrome}}
{{Wolff-Parkinson-White syndrome}}


{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{Sara.Zand}} {{CZ}}


==The Electrocardiogram in WPW==
==Overview==
# Two pathways between the [[atrium]] and the [[ventricle]] are present.
[[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. [[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 wave]]s suggestive of [[atrial fibrillation]] in the context of a [[heart rate]] higher than 240 beats per minute.
# There is a shortened [[PR interval]]
 
#* PR less than 0.12 seconds
==[[WPW]] Pattern==
#* In most cases it varies between 0.08 and 0.11 seconds
*[[WPW]] pattern is characterized by the following typical [[EKG]] findings:
# A [[wide QRS]] with a [[delta wave]].  
** 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]].
#* The [[QRS]] is 0.11 second or longer
**[[Wide QRS]]
#* Is inversely proportional to the [[PR interval|PR]] (i.e. the shorter the [[PR interval|PR]], the longer the [[QRS]] secondary to greater pre-excitation).
**[[delta wave]]
#* The combination of the shortened [[PR interval]] and widened [[QRS]] is of normal duration
**[[QRS alternans]]  
# The delta wave occurs as the ventricle is activated first via the accessory pathway (AP) and then normal activation follows down the normal pathway.
**[[ST segment depression]].
#* The duration of the delta wave is 0.03 to 0.06 seconds
*Preexcitation and presence of [[delta wave]]s typical of [[WPW syndrome]] or [[WPW pattern]] may either mimic [[myocardial infarction]] or may mask it.<ref name="pmid18602643">{{cite journal| author=Smolders L, Majidi M, Krucoff MW, Crijns HJ, Wellens HJ, Gorgels AP| title=Preexcitation and myocardial infarction: conditions with confusing electrocardiographic manifestations. | journal=J Electrocardiol | year= 2008 | volume= 41 | issue= 6 | pages= 679-82 | pmid=18602643 | doi=10.1016/j.jelectrocard.2008.05.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18602643  }} </ref><br>
# The pattern of ventricular activation is determined by several factors:
**Abolishment of [[delta waves]] may be necessary for the diagnosis of [[myocardial infarction]] on [[EKG]].<ref name="pmid23157811">{{cite journal| author=Liu R, Chang Q| title=The diagnosis of myocardial infarction in the Wolff-Parkinson-White syndrome. | journal=Int J Cardiol | year= 2013 | volume= 167 | issue= 3 | pages= 1083-4 | pmid=23157811 | doi=10.1016/j.ijcard.2012.10.055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23157811  }} </ref><br>
#* The location of the accessory pathway: The closer the accessory pathway to the [[SA node]], the quicker the impulse will reach the atrial insertion site of the AP. In contrast, in those patients in whom the AP is located in the far lateral region of the [[left ventricle]], contribution to the AP during NSR may be minimal.
**Left posterolateral or lateral [[accessory pathways]] may mask inferior or anteroseptal [[ myocardial infarction ]].<ref name="pmid7942468">{{cite journal| author=Preminger MW, Callans DJ, Gottlieb CD, Marchlinski FE| title=Radiofrequency catheter ablation used to unmask infarction Q waves in Wolff-Parkinson-White syndrome. | journal=Am Heart J | year= 1994 | volume= 128 | issue= 5 | pages= 1040-2 | pmid=7942468 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7942468  }} </ref><br>
#* The intra-atrial conduction time: Left atrial pathology will prolong the time necessary to reach the left sided AP, drugs can also prolong the time to reach a left-sided pathway.
**Posteroseptal accessory pathways may mask an [[anterior MI]].<ref name="pmid7942468">{{cite journal| author=Preminger MW, Callans DJ, Gottlieb CD, Marchlinski FE| title=Radiofrequency catheter ablation used to unmask infarction Q waves in Wolff-Parkinson-White syndrome. | journal=Am Heart J | year= 1994 | volume= 128 | issue= 5 | pages= 1040-2 | pmid=7942468 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7942468  }} </ref><br>
#* The conduction time over the accessory pathway: The conduction time over the AP depends on the length of the AP and velocity with which the impulse is conducted. Investigators have found that the accessory pathway may vary in length from 1 to 10 mm.
**Right anteroseptal and anterolateral [[accessory pathways]] may mask inferior or [[anterolateral MI]].<ref name="pmid7942468">{{cite journal| author=Preminger MW, Callans DJ, Gottlieb CD, Marchlinski FE| title=Radiofrequency catheter ablation used to unmask infarction Q waves in Wolff-Parkinson-White syndrome. | journal=Am Heart J | year= 1994 | volume= 128 | issue= 5 | pages= 1040-2 | pmid=7942468 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7942468  }} </ref>
#* The AV conduction time over the normal AV nodal-His-Purkinje pathway
# Secondary [[T wave]] changes:
#* Because of the early asynchronous activation of the [[ventricle]], the sequence of repolarization will be different leading to [[T wave]] changes.
#* The [[T wave]] polarity is opposite in direction to the delta wave
# Concealed bypass tracts:
#* If the accessory pathway's contribution to ventricular activation is minimal because of the coincidental arrival of the excitation wavefront over the normal pathway, then this should not be called a concealed accessory pathway.
#* Concealed accessory pathways are those that conduct in a retrograde fashion (ventriculoatrial) only.
#* Antegrade conduction in these patients is absent because the refractory period of the AP in the antegrade direction is longer than the sinus cycle length.
#* When a recurrent [[tachycardia]] occurs in association with such concealed bypass, the conduction is called concealed [[WPW syndrome]]
#* Are usually located on the left side of the cardiac chambers
#* Consider this if during the tachycardia there is a negative [[P wave]] in lead V1, if there is a [[P wave]] after the QRS complex
# Findings are intermittent in 1/2 the cases


== Determining the location of the accessory pathway==
== Determining the location of the accessory pathway==
{| class= "wikitable"
{{Family tree/start}}
|colspan = "6" align="left"| '''Check lead V1'''
{{Family tree | | | | | | | | | | | | | | | | B01 | | | |B01= V1}}
|-
{{Family tree | | | | | | | | | | | | | |,|-|-|^|-|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | | | |}}
|colspan ="3"| Negative delta wave in V1 = right ventricle
{{Family tree | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | |C02  |C01=_ | C02=+|}}
||
{{Family tree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
|colspan ="2"| Positive delta wave im V1= left ventricle
{{Family tree | | | | | | | | | | | | |  D1| | | | | | | | | | | | | | | | |  D1 | | | | | | | | | | | | | | | D1= Positive inferior leads| | | |}}
|-
{{Family tree | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | |}}
| 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
{{Family tree | | | | | | | | | | |D2 | |D3 | |D4 | | | | | | | |K2 | |K3 | |K4 | | | | | | | | | | |K4=0 |K3=1,2 |D4=3 | D3=1,2|D2=0 | K2=3|}}
|-
{{Family tree | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | |}}
| Posteroseptal || Right free wall || Anteroseptal ||||Posteroseptal || Lateral
{{Family tree | | | | | | | | | | |F1 | |F1 | |F1 | | | | | | |L1 | | |L2 | |L3 | | | | | | | | | | | | | | | | |F1=V3 |L1=Left lateral |L2= Left posterolateral | L3= V1/1 ratio| | |}}
|-
{{Family tree | | | | | | | | |,|-|^|.| | | |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | G1| | G2| |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | |G2=+ |G1=_ |}}
{{Family tree | | | | | | | | |!| | |!| | | |:| | | | |:| | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | |H1 | |H2 | |:| | | | |:| | | | | | | | | | | | | | |J1 | | J2| | | | | | | | | | | |J1= <1 |J2=≥1 | H2=Right paraseptal|H1=Right posterior| |}}
{{Family tree | | | | | | | | | | | | |,|-|-|^|.| | | |:| | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | H3| | |H4 | |:| | | | | | | | | | | | | | | M1| | |N1 | | | | | | | | | | | |M1=Lead 2, Notched QS | N1=Left posterolateral| H3=_|H4=+ |}}
{{Family tree | | | | | | | | | | | | |!| | | |!| | | |:| | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | |H5 | |H6 | | |:| | | | | | | | | | | | | Y1| | Y2| | | | | | | | | |Y2=NO |Y1= Yes |H6=[[Nodo-Hisian]] |H5=Right lateral |}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|-|-|^|.| | | | | | | | | | | |!| | | |!| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |j1 | | |j2 | | | | | | | | | |Y3 | |Y4 | | | | | | | | | |Y4=Left paraseptal |Y3=Deep coronary sinus | j1=_| j2=+| }}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |J3 | | | J4| | | | | | | | | | | | | | | | | | | | | | | | | | |J3=[[Nodo-Hisian]] | |J4=[[Right atrium]] | |}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2019 ESC Guideline<ref name="pmid31504425">{{cite journal |vauthors=Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A |title=2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC) |journal=Eur Heart J |volume=41 |issue=5 |pages=655–720 |date=February 2020 |pmid=31504425 |doi=10.1093/eurheartj/ehz467 |url=}}</ref>
|-  
|}
|}


==Oversimplification==
==[[WPW Syndrome]]==
Histological studies have found that the AP fibers may insert in the septum and not the free wall as above. The location of AP may be impossible to determine in NSR, as it can be complicated by the existence of more than one AP in some patients, the coexistence of congenital lesions, the occasional superimposition of the P wave on the initial portion of the delta wave, and differences in the activation depending on whether the AP is epicardially or endocardially located.  
*[[WPW syndrome]] is the occurrence of [[tachycardia]] with or without associated symptoms in a subject with existing [[WPW]] pattern.<ref>{{Cite web  | last =  | first =  | title = Wolff-Parkinson-White Syndrome and Accessory Pathways | url = http://circ.ahajournals.org/content/122/15/e480.full | publisher =  | date =  | accessdate = 1 April 2014 }}</ref> 
*Several types of [[ arrhythmia]] can occur in [[WPW syndrome]] such as [[AV reentrant tachycardia]] (AVRT), [[atrial fibrillation]],or [[atrial flutter]]
the most common type of [[tachyarrhythmia]] is [[AVRT]].<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>
 
====[[Orthodromic AVRT]]====
*In orthodromic AVRT, the anterograde conduction (from the [[atrium]] to the [[ventricle]]) passes through the[[ AV 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]]<br>
* Narrow [[QRS complex]]es <br>
* Retrograde [[P wave]] following the [[QRS]] complex <br>
* Long RP, short PR tachycardia
[[File:SVT.jpg|800px|center]]
 
====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]].<br>
*The [[EKG]] findings may include the following:
* Regular [[rhythm]]<br>
* [[Wide QRS complexes]] [[tachycardia]] <br>
 
[[File:Wide complex tachy.jpg|800px|center]]


==Associated Cardiovascular Abnormalities==
==[[Atrial Fibrillation]] in [[WPW]]==
# Type B is found in 5% to 25% of the reported cases of [[Ebstein's anomaly]]. Suspect this if there is Type B WPW with [[RBBB]].
*[[Atrial fibrillation]] in [[WPW]] syndrome is life-threatening because it might lead to [[ventricular tachycardia]].  
# Also been found in patients with corrected [[transposition of the great arteries]], [[tricuspid atresia]], [[endocardial fibroelastosis]], [[MVP]], [[cardiomyopathies]] (hypertrophic obstructive and congestive).
* 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<ref name="KleinBashore1979">{{cite journal|last1=Klein|first1=George J.|last2=Bashore|first2=Thomas M.|last3=Sellers|first3=T. D.|last4=Pritchett|first4=Edward L. C.|last5=Smith|first5=William M.|last6=Gallagher|first6=John J.|title=Ventricular Fibrillation in the Wolff-Parkinson-White Syndrome|journal=New England Journal of Medicine|volume=301|issue=20|year=1979|pages=1080–1085|issn=0028-4793|doi=10.1056/NEJM197911153012003}}</ref>


==Clinical Manifestations==
# The most common form of paroxysmal tachycardia in these patients is a circus movement tachycardia (CMT) incorporating the AP.
# The CMT utilizes the following structures: the AV node, the His-Purkinje system, the ventricular myocardium (from the terminal portion of the His system to the ventricular end of the AP), the AP itself, and the atrial myocardium itself from the atrial insertion of the AP to the AV node.
# This circuit can conduct in both directions:
#* Type I A CMT:
#*:# This is the usual form of the CMT in patients with WPW.
#*:# Is antegrade through the [[AV node]], VA conduction through the AP.
#*:# The QRS complex during the tachycardia shows either normal intraventricular conduction or typical bundle branch block configuration.
#*:# Symptoms: [[Palpitations]] (97%), [[dyspnea]] (57%), anginal pain (56%), [[perspiration]] (55%), [[fatigue]] (41%), [[anxiety]] (30%), [[dizziness]] (30%),[[polyuria]] (26%).
#*:# This is also called orthodromic reentrant tachycardia.
#*:# There is no delta wave.
#*:# The rate is 140 to 250 bpm.
#*:# It is faster than the rate of tachycardia due to reentry in the AV node.
#*:# Often triggered by a PAC
#* Type I B CMT:
#*:# Anterograde down the accessory pathway, retrograde in the AVN-His pathway.
#*:# The QRS is widened ([[wide QRS]])
#*:# This form is rare.
#* Type II CMT (intra-AV nodal):
#*:# Anterograde pathway is an AV nodal slow pathway, the retrograde pathway is an AV nodal fast pathway.
#*:# No evidence of ventricular pre-excitation during the tachycardia.
#* Type III CMT (uses two accessory pathways):
#*:# Conducts anterograde down one accessory pathway and retrograde up a second accessory pathway.
#*:# These patients can also experience atrial tachycardias and ventricular tachycardias.


==Atrial Fibrillation in WPW==
Shown below is an [[ECG]] depicting an irregularly irregular rhythm with [[wide QRS]] and absent [[P waves]] suggestive of [[atrial fibrillation]] in [[WPW syndrome]].
Can cause life-threatening ventricular rates due to the exclusive AV conduction over the accessory pathway.
 
#* Reduces cardiac output.
[[File:Wpw with afib.PNG|center|300px]]
#* May degenerate into VF, particularly in those with multiple bypass tracts.
# The only marker identified for degeneration into VF in the literature was the occurrence of RR intervals equal to or less than 205 msec during the a fib
# Seen in 78 of 256 of Wellen's patients with WPW. Reported incidence is 20 to 35% in other studies.
# The degree of ventricular preexcitation observed in the EKG during NSR bears no relationship whatsoever to the risk of developing life-threatening ventricular rates during the a.fib.
# The QRS complexes are wide and bizarre as a result of preexcitation.
# The ventricular rate is 220 to 360 beats per minute due to the short effective refractory period of the accessory pathway.
# It is often mistaken for VT.
# If the atrial rate in atrial fibrillation is greater than 200 BPM then suspect this. The rhythm will also be grossly irregular if it is due to atrial fibrillation. Such a rapid rate would be unusual if it were due to conduction by way of the normal AV conduction system.


==Examples==
==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]].[[File:Rhythm_WPW.png|center|800px]]
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]].[[File:Rhythm_WPW.png|center|800px]]
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
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.
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]].
[[Image:Wolf_Parkinson_White_syndrome.png|center|800px]]
[[Image:Wolf_Parkinson_White_syndrome.png|center|800px]]
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
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----
----


Shown below is an example of an ECG demonstrating a delta wave in lead [[Precordial leads|V<sub>2</sub>]] along with [[left axis deviation]].
Shown below is an [[EKG]] demonstrating a [[delta wave]] in leads [[Precordial leads|V<sub>2</sub>]], I, aVL, with [[wide QRS complexes]] and [[left axis deviation]] suggesting [[WPW syndrome]].
[[Image:WPW_syndrome_1.jpg|center|800px]]
[[Image:WPW_syndrome_1.jpg|center|800px]]
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
Line 108: Line 104:
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----


Shown below is an example of an ECG showing a [[short PR interval]] of less than 120 ms, delta waves in leads [[Limb lead|I]], [[Augmented limb lead|aVF]], [[Augmented limb lead|aVL]] and chest leads with [[wide QRS]] complexes indicating [[WPW syndrome]].
Shown below is an [[EKG]] showing a [[short PR interval]] of less than 120 ms, delta waves in leads [[Limb lead|I]], [[Augmented limb lead|aVF]], [[Augmented limb lead|aVL]] and [[chest]] leads with [[wide QRS]] complexes indicating [[WPW syndrome]].
[[Image:WPW_syndrome_2.jpg|center|800px]]
[[Image:WPW_syndrome_2.jpg|center|800px]]
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
Line 114: Line 110:
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;For more EKG examples of Wolff-Parkinson-White syndrome click [[Wolff-Parkinson-White syndrome EKG examples|here]].
; For more [[EKG]] examples of [[Wolff-Parkinson-White syndrome]] click [[Wolff-Parkinson-White syndrome]] [[EKG]] examples here.


==References==
==References==
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[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Disease]]
[[Category:Needs overview]]
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{{WH}}
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Latest revision as of 11:33, 19 August 2022

Wolff-Parkinson-White syndrome Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]

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. 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

Determining the location of the accessory pathway

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
V1
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
_
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
+
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive inferior leads
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive inferior leads
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
0
 
1,2
 
3
 
 
 
 
 
 
 
3
 
1,2
 
0
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
V3
 
V3
 
V3
 
 
 
 
 
 
Left lateral
 
 
Left posterolateral
 
V1/1 ratio
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
_
 
+
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Right posterior
 
Right paraseptal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
<1
 
≥1
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
_
 
 
+
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lead 2, Notched QS
 
 
Left posterolateral
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Right lateral
 
Nodo-Hisian
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
_
 
 
+
 
 
 
 
 
 
 
 
 
Deep coronary sinus
 
Left paraseptal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nodo-Hisian
 
 
Right atrium
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The above algorithm adopted from 2019 ESC Guideline[4]

WPW Syndrome

the most common type of tachyarrhythmia is AVRT.[6]

Orthodromic AVRT

The EKG findings include the following:

Antidromic AVRT

Atrial Fibrillation in WPW


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.

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.

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.

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.

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

  1. ↑ 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.
  2. ↑ 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.
  3. ↑ 3.0 3.1 3.2 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.
  4. ↑ Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A (February 2020). "2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC)". Eur Heart J. 41 (5): 655–720. doi:10.1093/eurheartj/ehz467. PMID 31504425.
  5. ↑ "Wolff-Parkinson-White Syndrome and Accessory Pathways". Retrieved 1 April 2014.
  6. ↑ "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.
  7. ↑ 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.

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