Wolff-Parkinson-White syndrome resident survival guide: Difference between revisions

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{{CMG}}; {{AE}} [[User:Alonso Alvarado|Alonso Alvarado, M.D.]]; {{Hilda}}; {{AL}}
{{CMG}}; {{AE}} {{Alonso}}; {{Hilda}}; {{AL}}


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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Wolff-Parkinson-White syndrome resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Wolff-Parkinson-White syndrome resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Wolff-Parkinson-White syndrome resident survival guide#Complete Diagnostic Approach|Diagnosis]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Wolff-Parkinson-White syndrome resident survival guide#Complete Diagstic Approach|Diagsis]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Wolff-Parkinson-White syndrome resident survival guide#Treatment|Treatment]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Wolff-Parkinson-White syndrome resident survival guide#Treatment|Treatment]]
:[[Wolff-Parkinson-White syndrome resident survival guide#Initial Treatment|Initial]]
: [[Wolff-Parkinson-White syndrome resident survival guide#Initial Treatment|Initial]]
:[[Wolff-Parkinson-White syndrome resident survival guide#Long-Term Treatment|Long-term]]
: [[Wolff-Parkinson-White syndrome resident survival guide#Long-Term Treatment|Long-term]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Wolff-Parkinson-White syndrome resident survival guide#Do's|Do's]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Wolff-Parkinson-White syndrome resident survival guide#Do's|Do's]]
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==FIRE: Focused Initial Rapid Evaluation==
==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<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><ref name="ACLS">{{Cite web  | last =  | first =  | title = Part 8: Adult Advanced Cardiovascular Life Support | url = http://circ.ahajournals.org/content/122/18_suppl_3/S729.full | publisher =  | date =  | accessdate = 3 April 2014 }}</ref> <br> <span style="font-size:85%">Boxes in salmon color signify that an urgent management is needed.</span>
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<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><ref name="ACLS">{{Cite web  | last =  | first =  | title = Part 8: Adult Advanced Cardiovascular Life Support | url = http://circ.ahajournals.org/content/122/18_suppl_3/S729.full | publisher =  | date =  | accessdate = 3 April 2014 }}</ref> <br> <span style="font-size:85%">Boxes in red signify that an urgent management is needed.</span>
 
<span style="font-size:85%"> '''Abbreviations:''' '''AF:''' [[atrial fibrillation]]; '''AVRT''': [[AV reentrant tachycardia]]; '''BP:''' [[blood pressure]];  '''ECG:''' [[electrocardiography]]; '''HF:''' [[heart failure]]; '''LVH:''' [[left ventricular hypertrophy]]; '''WPW:''' [[WPW|Wolff-Parkinson-White pattern]]</span>


{{Family tree/start}}
{{Family tree/start}}
{{familytree | | | | | A00 | | | | | | | | | A00= <div style="float: left; text-align: left; width: 28em; padding:1em;">'''Identify cardinal findings that increase the pretest probability of [[Wolff-Parkinson-White syndrome]]'''<br>
{{familytree | | | | | | | | A00 | | | | | | | | | A00= <div style="float: left; text-align: left; width: 28em; padding:1em;">'''Identify cardinal findings that increase the pretest probability of [[Wolff-Parkinson-White syndrome]]'''<br>
❑ Baseline [[ECG]] findings suggestive of [[WPW]] pattern ([[pre-excitation]])
❑ Baseline [[ECG]] findings suggestive of [[WPW]] pattern ([[pre-excitation]])
:❑ [[Delta wave]]
: ❑ [[Short PR interval|PR interval (&lt;120 ms)]]
:❑ Short [[PR interval]]
: ❑ [[Delta wave]] <br>&nbsp;&nbsp;&nbsp;[[File:WPW EKG leadV2.png|100px]]
'''AND'''<br>
'''AND'''<br>
❑ [[Tachyarrhythmia]]<br>
❑ [[Tachyarrhythmia]]<br>
'''''[[ECG]] findings suggestive of [[AVRT]]'''''
 
:❑ Regular rhythm
'''''[[ECG]] findings suggestive of orthodromic [[AVRT]]'''''
:❑ Rate over 150 bpm
: ❑ Ventricular rate usually 200–300 bpm
:❑ [[Narrow QRS complex]] preceded by a [[P wave]] (suggestive of orthodrome [[AVRT]])
: ❑ Regular, narrow [[QRS complex]] (usually &lt;120 ms unless pre-existing [[bundle branch block]] or [[aberrant conduction]])
:❑ [[Wide QRS complex]] followed by a retrograde [[P wave]] (suggestive of antidrome [[AVRT]])
: ❑ [[P wave]]s may be buried in the [[QRS complex|QRS]] or [[retrograde P wave|retrograde]]
'''''[[ECG]] findings suggestive of [[AF]] + [[WPW]]'''''
: ❑ [[Delta wave]] may be lost during [[NSR]] in case of participating concealed bypass tract
:❑ Irregularly irregular [[rhythm]]
 
:❑ Absent [[P waves]]
'''''[[ECG]] findings suggestive of antidromic [[AVRT]]'''''
:❑ [[Heart rate]] > 220 [[beats per minute]]
: ❑ Ventricular rate usually 200–300 bpm
</div>}}
: ❑ Regular, [[wide QRS complex]]
{{familytree | | | | | |!| | | | | | | | | | }}
: ❑ [[Delta wave]] is observed during [[NSR]]
{{familytree | | | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 28em; padding:1em;">'''Does the patient have any of the following findings that require urgent [[cardioversion]]?''' <br>
 
'''''[[ECG]] findings suggestive of [[AF]] with [[WPW]]'''''
: ❑ Ventricular rate usually &gt;200 bpm
: ❑ Irregularly irregular, [[wide QRS complex]] with varying morphology
: ❑ Absence of [[P waves]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | | | | }}
{{familytree | | | | | | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 28em; padding:1em;">'''Does the patient have any of the following findings that require urgent [[cardioversion]]?''' <br>
❑ Hemodynamic instability
❑ Hemodynamic instability
:❑ [[Hypotension]]
:❑ [[Hypotension]]
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❑ [[Chest discomfort]] suggestive of [[ischemia]] <br>
❑ [[Chest discomfort]] suggestive of [[ischemia]] <br>
❑ [[Heart failure|Decompensated heart failure]]<br></div>}}
❑ [[Heart failure|Decompensated heart failure]]<br></div>}}
{{familytree | | |,|-|-|^|-|-|.| | | | |}}
{{familytree | | | | | |,|-|-|^|-|-|.| | | | |}}
{{familytree | | B01 | | | | B02 | | | | B01=<div style="float: left; background: #FA8072; width: 20em; padding:1em;"> {{fontcolor|#F8F8FF|'''Yes'''}}</div> | B02= '''No'''}}
{{familytree |boxstyle=padding: 0px;  | | | | | B01 | | | | B02 | | | |B01=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 5px; font-weight: bold;">YES</div>| B02=<div style="text-align: center; font-weight: bold;">NO</div>}}
{{familytree | | |!| | | | | |!| | | | }}
{{familytree |boxstyle=border-top: 0px; padding: 0px;| | | | | C01 | | | | C02 | | |C01=<div style="text-align: center; background: #FA8072; color: #F8F8FF; font-weight: bold; padding: 15px;">Perform <BR> electrical cardioversion</div>|C02=<div style="text-align: left">'''[[Wolff-Parkinson-White syndrome resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree | | C01 | | | | C02 | | | C01= <div style="float: left; text-align: left; background: #FA8072; width: 20em; padding:1em;"> {{fontcolor|#F8F8FF| Does the patient have a [[Wide complex tachycardia|<span style="color:white;">wide irregular rhythm</span>]]?}} </div> | C02= <div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Wolff-Parkinson-White syndrome resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree | | | | | |!| | | |}}
{{familytree | |,|^|-|.| | | | | | | }}
{{familytree |boxstyle=padding: 0px;   | | | | | Y01 | | |Y01=<div style="text-align: left; background: #FA8072; color: #F8F8FF; padding: 5px; font-size:85%">
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| D01 | | D02 | | D01= Yes| D02= No}}
<BIG>'''''Irregular wide QRS complex'''''</BIG>
{{familytree | |!| | | |!| | }}
: ❑ Unsynchronized, biphasic 120–200 J '''''OR'''''
{{familytree | boxstyle=background: #FA8072; color: #F8F8FF;| E01 | | E02 | | E01= <div style="float: left; text-align: left; background: #FA8072; width: 20em; padding:1em;"> {{fontcolor|#F8F8FF| Perform urgent '''unsynchronized''' electrical [[Cardioversion|<span style="color:white;">cardioversion</span>]]<br>  
: ❑ Unsynchronized, monophasic 360 J
:❑ 200-360 Joules monophasic, or
<BIG>'''''Irregular narrow QRS complex'''''</BIG>
:❑ 100-200 Joules biphasic}} </div>| E02=<div style="float: left; text-align: left; background: #FA8072; width: 28em; padding:1em;"> {{fontcolor|#F8F8FF| ❑ Perform urgent '''synchronized''' electrical [[Cardioveersion|<span style="color:white;">cardioversion</span>]]<br>
: ❑ Synchronized, biphasic 120–200 J '''''OR'''''
:❑ [[Narrow complex tachycardia|<span style="color:white;">Narrow regular rhythm</span>]]: 50-100 Joules<br>
: ❑ Synchronized, monophasic 200 J
:[[Narrow complex tachycardia|<span style="color:white;">Narrow regular rhythm</span>]]: 120-200 Joules biphasic or 200 Joules monophasic<br>
❑ <BIG>'''''Regular wide QRS complex'''''</BIG>
:[[Wide complex tachycardia|<span style="color:white;">Wide irregular rhythm</span>]]}}
: ❑ Synchronized, biphasic or monophasic 100 J
</div> }}
❑ <BIG>'''''Regular narrow QRS complex'''''</BIG>
{{familytree | |!| | | |!| | | | | |}}
: ❑ Synchronized, biphasic or monophasic 50–100 J
{{familytree | F01 | | F02 | | F01=<div style="float: left; text-align: left; width: 15em; padding:1em;">❑ '''[[Wolff-Parkinson-White syndrome resident survival guide#Complete Diagnostic Approach|After stabilizing the patient, continue with the complete diagnostic approach below]]''' </div>|F02=<div style="float: left; text-align: left; width: 28em; padding:1em;">'''[[Wolff-Parkinson-White syndrome resident survival guide#Complete Diagnostic Approach|After stabilizing the patient, continue with the complete diagnostic approach below]]''' </div>}}
</div>}}
{{familytree | | | | | |!| | | |}}
{{familytree |boxstyle=padding: 0px;  | | | | | Z01 | | |Z01=<div style="text-align: left; font-weight: bold; padding: 5px;">'''[[Wolff-Parkinson-White syndrome resident survival guide#Complete Diagnostic Approach|After stabilizing the patient, continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}
{{familytree/end}}
<br>


==Complete Diagnostic Approach==
==Complete Diagnostic Approach==
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{{familytree  | | | | | F01 | | | F01= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Order studies:'''<br>
{{familytree  | | | | | F01 | | | F01= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Order studies:'''<br>
❑ [[ECG]] <br>
❑ [[ECG]] <br>
❑ [[Echocardiography]] searching for: <br>
❑ [[Echocardiography]] screening for: <br>
:❑ [[Hypertrophic cardiomyopathy]]
:❑ [[Hypertrophic cardiomyopathy]]
:❑ [[Ebstein's anomaly of the tricuspid valve]]
:❑ [[Ebstein's anomaly of the tricuspid valve]]
</div>}}
</div>}}
{{familytree  | |,|-|-|-|+|-|-|-|.| | | |}}
{{familytree  | |,|-|-|-|+|-|-|-|.| | | |}}
{{familytree  | D01 | | D02 | | D03 | | | D01= <div style="float: left; text-align: left; width: 24em; padding:1em;">'''[[WPW]] with [[AF]]'''<br>
{{familytree  |boxstyle=vertical-align: top;| D01 | | D02 | | D03 | | | D01= <div style="float: left; text-align: left; width: 24em; padding:1em;">'''[[WPW]] with [[AF]]'''<br>
''Suspect when [[AF]] appears with heart rates of 220 to 360.''<br>
Suspect when [[AF]] appears with heart rates of 220 to 360<br>
 
❑ Irregularly irregular, [[wide QRS complex]] with varying morphology<br>
❑ Irregularly irregular rhythm<br>
Absence of [[P waves]]<ref name="FenglerBrady2007">{{cite journal|last1=Fengler|first1=Brian T.|last2=Brady|first2=William J.|last3=Plautz|first3=Claire U.|title=Atrial fibrillation in the Wolff-Parkinson-White syndrome: ECG recognition and treatment in the ED|journal=The American Journal of Emergency Medicine|volume=25|issue=5|year=2007|pages=576–583|issn=07356757|doi=10.1016/j.ajem.2006.10.017}}</ref><br>[[File:Wpw with afib.PNG|center|300px]]
❑ Rapid ventricular response (over 220 bpm)<br>
[[Wide QRS complex]]<br>
No [[P wave]]<ref name="FenglerBrady2007">{{cite journal|last1=Fengler|first1=Brian T.|last2=Brady|first2=William J.|last3=Plautz|first3=Claire U.|title=Atrial fibrillation in the Wolff-Parkinson-White syndrome: ECG recognition and treatment in the ED|journal=The American Journal of Emergency Medicine|volume=25|issue=5|year=2007|pages=576–583|issn=07356757|doi=10.1016/j.ajem.2006.10.017}}</ref>[[File:Wpw with afib.PNG|center|300px]]
</div>|
</div>|
D02= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Orthodromic AVRT''' <br>
D02= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Orthodromic AVRT''' <br>
❑ [[Pulse|Regular rhythm]]<br>
Ventricular rate usually 200–300 bpm<br>
❑ [[Narrow complex tachycardia resident survival guide|Narrow QRS complexes]] <br>
❑ Regular, narrow [[QRS complex]] (usually &lt;120 ms unless pre-existing [[bundle branch block]] or [[aberrant conduction]])<br>
❑ [[P wave]] before [[QRS]]<br>
❑ [[P wave]]s may be buried in the [[QRS complex|QRS]] or [[retrograde P wave|retrograde]]<br>
❑ [[Delta wave]] may be lost during [[NSR]] in case of participating concealed bypass tract<br>
[[File:SVT.jpg|300px|center]]
[[File:SVT.jpg|300px|center]]
</div> |
</div> |
D03= <div style="float: left; text-align: left; width: 24em; padding:1em;"> '''Antidromic AVRT''' <br>
D03= <div style="text-align: left; width: 24em; padding:1em;"> '''Antidromic AVRT'''<br>
[[Pulse|Regular rhythm]]<br>
Ventricular rate usually 200–300 bpm<br>
❑ [[Wide complex tachycardia resident survival guide|Wide QRS complexes]] <br>
Regular, [[wide QRS complex]]<br>
❑ [[P wave]] after [[QRS]] <br>
❑ [[Delta wave]] is observed during [[NSR]]<br>
[[File:Wide complex tachy.jpg|300px|center]]
[[File:Wide complex tachy.jpg|300px|center]]
</div> }}
</div> }}
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{{familytree/start}}
{{familytree/start}}
{{familytree  | | | | A01 | | | A01= <div style="float: left; text-align: left; width: 28em; padding:1em;">'''Does the patient have any of the following findings that require urgent cardioversion?''' <br>
{{familytree  | | | | A01 | | | A01= <div style="text-align: left; padding:1em;">'''Does the patient have any of the following findings that require urgent cardioversion?''' <br>
❑ Hemodynamic instability
❑ Hemodynamic instability
:❑ [[Hypotension]]
:❑ [[Hypotension]]
Line 207: Line 214:
{{familytree  | D01 | | | | D02 | | | | D01= '''Yes'''| D02= '''No'''}}
{{familytree  | D01 | | | | D02 | | | | D01= '''Yes'''| D02= '''No'''}}
{{familytree  | |!| | | | | |!| | | | }}
{{familytree  | |!| | | | | |!| | | | }}
{{familytree  | E01 | | | | E02 | | | |  E01=<div style="float: left; text-align: left; width: 24em"><br> ❑ [[Direct current cardioversion]] (Urgent) <br> ''Check [[Wolff-Parkinson-White syndrome resident survival guide#FIRE:Focused Initial Rapid Evaluation|FIRE]] for details'' </div>
{{familytree  | E01 | | | | E02 | | | |  E01=<div style="text-align: left">❑ [[Direct current cardioversion]] (Urgent) <br> ''Check [[Wolff-Parkinson-White syndrome resident survival guide#FIRE:Focused Initial Rapid Evaluation|FIRE]] for details'' </div>
|E02=<div style="float: left; text-align: left"> '''What is the type of [[tachycardia]] according to the [[ECG]] findings?'''
|E02=<div style="text-align: left"> '''What is the type of [[tachycardia]] according to the [[ECG]] findings?'''
</div>}}
</div>}}
{{familytree  | | | | | | | |!| | | | }}
{{familytree  | | | | | | | |!| | | | }}
{{familytree  | |,|-|-|-|v|-|^|-|.| | | | | }}
{{familytree  | |,|-|-|-|v|-|^|-|.| | | | | }}
{{familytree  | F00 | | F01 | | F02 | | | | | F00= '''WPW+AF'''| F01= '''Orthodromic AVRT'''| F02= '''Antidromic AVRT'''}}
{{familytree  | F00 | | F01 | | F02 | | | | | F00= '''WPW + AF (Stable)'''| F01= '''Orthodromic AVRT (Stable)'''| F02= '''Antidromic AVRT (Stable)'''}}
{{familytree  | |!| | | |!| | | |!| | | | | |}}
{{familytree  | |!| | | |!| | | |!| | | | | |}}
{{familytree  | G00 | | G01 | | G02 | | | |G00= <div style="float: left; text-align: left; width: 27em; padding:1em;">
{{familytree  |boxstyle=vertical-align: top;| G00 | | G01 | | G02 | | | |G00=<div style="text-align: left; padding: 1em;">
<span style="font-size:100%;color:red"> '''Avoid the use of AV node blocking agents such as digoxin, calcium channel blockers, beta blockers and adenosine.'''</span><br><br>
<span style="font-size: 100%; color: red;"> '''Avoid the use of AV node blocking agents such as digoxin, calcium channel blockers, beta blockers and adenosine.'''</span><br><br>
❑ Administer [[procainamide]], 100 mg [[infusion]] diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])<ref name="pmid23545139">{{cite journal| author=American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB et al.| title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 18 | pages= 1916-26 | pmid=23545139 | doi=10.1161/CIR.0b013e318290826d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23545139  }} </ref><br>
❑ Administer [[procainamide]], 100 mg [[infusion]] diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])<ref name="pmid23545139">{{cite journal| author=American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB et al.| title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 18 | pages= 1916-26 | pmid=23545139 | doi=10.1161/CIR.0b013e318290826d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23545139  }} </ref><br>
:❑ Administer until the [[arrhythmia]] is suppressed or until 500 mg has been administered<br>
:❑ Administer until the [[arrhythmia]] is suppressed or until 500 mg has been administered<br>
:❑ Wait 10 minutes or longer to administer new [[dosage]]
:❑ Wait 10 minutes or longer to administer new [[dosage]]
:<span style="font-size:85%;color:red">Contraindications: [[<span style="font-size:85%;color:red">complete heart block</span>]], [[<span style="font-size:85%;color:red">lupus erythematosus</span>]], [[<span style="font-size:85%;color:red">Hypersensitivity|idiosyncratic hypersensitivity</span>]], [[<span style="font-size:85%;color:red">torsades de pointes</span>]]</span><br>
:[[Contraindication|<span style="font-size:85%;color:red">Contraindications:</span>]] [[Third degree AV block|<span style="font-size:85%;color:red">third degree AV block</span>]], [[Systemic lupus erythematosus|<span style="font-size:85%;color:red">lupus erythematosus</span>]], [[Hypersensitivity|<span style="font-size:85%;color:red">idiosyncratic hypersensitivity</span>]], [[Torsades de pointes|<span style="font-size:85%;color:red">torsades de pointes</span>]]<br>
''Or''<br>❑ Administer [[ibutilide]] 1 mg IV [[infusion]] over 10 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])<ref name="pmid23545139">{{cite journal| author=American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB et al.| title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 18 | pages= 1916-26 | pmid=23545139 | doi=10.1161/CIR.0b013e318290826d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23545139  }} </ref><br>
<CENTER>'''''OR'''''</CENTER>
 
❑ Administer [[ibutilide]] 1 mg IV [[infusion]] over 10 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])<ref name="pmid23545139">{{cite journal| author=American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB et al.| title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 18 | pages= 1916-26 | pmid=23545139 | doi=10.1161/CIR.0b013e318290826d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23545139  }} </ref><br>
:❑ Repeat the [[dosage]] if the [[tachycardia]] continues <br>
:❑ Repeat the [[dosage]] if the [[tachycardia]] continues <br>
:<span style="font-size:85%;color:red">Contraindications: hypersensitivity to ibutilide or any component of the formulation, QTc >440 msec</span><br>
:<span style="font-size:85%;color:red">[[Contraindication|<span style="color:red">Contraindications:</span>]] [[Hypersensitivity|<span style="color:red">hypersensitivity</span>]] to [[Ibutilide|<span style="color:red">ibutilide</span>]] or any component of the formulation, [[QT interval|<span style="color:red">QTc</span>]] >440 msec</span><br>
''Or''<br>
<CENTER>'''''OR'''''</CENTER>
 
❑ Administer [[flecainide]] 50 mg every 12 hours ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])<ref name="pmid23545139">{{cite journal| author=American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB et al.| title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 18 | pages= 1916-26 | pmid=23545139 | doi=10.1161/CIR.0b013e318290826d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23545139  }} </ref>
❑ Administer [[flecainide]] 50 mg every 12 hours ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])<ref name="pmid23545139">{{cite journal| author=American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB et al.| title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 18 | pages= 1916-26 | pmid=23545139 | doi=10.1161/CIR.0b013e318290826d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23545139  }} </ref>
:❑ Increase 50mg BID every four days until efficacy is achieved <br>
:❑ Increase 50mg BID every four days until efficacy is achieved <br>
:❑ Maximum [[dose]] recommended for [[SVT]] is 300 mg/day<br>
:❑ Maximum [[dose]] recommended for [[SVT]] is 300 mg/day<br>
:<span style="font-size:85%;color:red">Contraindications: pre-existing second- or third-degree AV block, right bundle branch block associated with a left hemiblock unless a pacemaker is present, cardiogenic shock, hypersensitivity to the drug</span><br>
:<span style="font-size:85%;color:red">[[Contraindication|<span style="color:red">Contraindications:</span>]] pre-existing [[Second degree AV block|<span style="color:red">second degree AV block</span>]] or [[Third degree AV block|<span style="color:red">third degree AV block</span>]] , [[Right bundle brnach block|<span style="color:red">right bundle branch block</span>]] associated with a left hemiblock unless a [[Artificial pacemaker|<span style="color:red">pacemaker</span>]] is present, [[Shock|<span style="color:red">cardiogenic shock</span>]], [[Hypersensitivity|<span style="color:red">hypersensitivity</span>]] to the drug</span><br>
</div>
</div>
|G01= <div style="float: left; text-align: left; width: 24em; padding:1em;"> <br>
|G01= <div style="text-align: left; padding: 1em;">❑ Use [[vagal maneuvers]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br>
❑ Use [[vagal maneuvers]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br>
:❑ [[Carotid sinus massage]] <br>
:❑ [[Carotid sinus massage]] <br>
:❑ [[Valsalva maneuver]] <br>
:❑ [[Valsalva maneuver]] <br>
Line 236: Line 245:
❑ Administer [[adenosine]] 6 mg IV (bolus) ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]])<br>
❑ Administer [[adenosine]] 6 mg IV (bolus) ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]])<br>
: ❑ If initial [[dose]] is not effective, administer a second [[dose]] of 12 mg, repeated a second time if required<br>  
: ❑ If initial [[dose]] is not effective, administer a second [[dose]] of 12 mg, repeated a second time if required<br>  
:<span style="font-size:85%;color:red">Contraindications: second- or third-degree A-V block (except in patients with a functioning artificial pacemaker<br></span><br>
:<span style="font-size:85%;color:red">[[Contraindication|<span style="color:red">Contraindications:</span>]] [[Second degree AV block|<span style="color:red">second degree AV block</span>]] or [[Third degree AV block|<span style="color:red">third degree AV block</span>]]  unless a [[Artificial pacemaker|<span style="color:red">pacemaker</span>]] is present</span><br>
''If not effective''<br><br>
''If not effective''<br><br>
❑ Administer [[verapamil]] 5 to 10 mg (0.075 to 0.15 mg/kg body weight) IV [[Bolus|boluses]] of  over 2 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]])<br>
❑ Administer [[verapamil]] 5 to 10 mg (0.075 to 0.15 mg/kg body weight) IV [[Bolus|boluses]] of  over 2 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]])<br>
: ❑ Give 30% of the [[dose]] in case of [[hepatic impairment]]<br>
: ❑ Give 30% of the [[dose]] in case of [[hepatic impairment]]<br>
: ❑ Monitor for prolonged PR interval in case of [[renal impairment]]<br>
: ❑ Monitor for [[prolonged PR interval]] in case of [[renal impairment]]<br>
:<span style="font-size:85%;color:red">Contraindications: severe left ventricular dysfunction, hypotension (systolic pressure less than 90 mm Hg) or cardiogenic shock</span><br>
:<span style="font-size:85%;color:red">[[Contraindication|<span style="color:red">Contraindications:</span>]] [[Congestive heart failure|<span style="color:red">severe left ventricular dysfunction</span>]], [[Hypotension|<span style="color:red">hypotension</span>]]  or [[Shock|<span style="color:red">cardiogenic shock</span>]]</span><br>
''If not effective''<br><br>
''If not effective''<br><br>
❑ Administer [[procainamide]], 100 mg [[infusion]] diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br>
❑ Administer [[procainamide]], 100 mg [[infusion]] diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br>
Line 247: Line 256:
:❑ Wait 10 minutes or longer to administer new dosage <br>
:❑ Wait 10 minutes or longer to administer new dosage <br>
:❑ [[Dosage]] should be adjusted for the individual patient in case of [[renal impairment]]<br>
:❑ [[Dosage]] should be adjusted for the individual patient in case of [[renal impairment]]<br>
:<span style="font-size:85%;color:red">Contraindications: complete heart block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes</span><br></div>
:[[Contraindication|<span style="font-size:85%;color:red">Contraindications:</span>]] [[Third degree AV block|<span style="font-size:85%;color:red">third degree AV block</span>]], [[Systemic lupus erythematosus|<span style="font-size:85%;color:red">lupus erythematosus</span>]], [[Hypersensitivity|<span style="font-size:85%;color:red">idiosyncratic hypersensitivity</span>]], [[Torsades de pointes|<span style="font-size:85%;color:red">torsades de pointes</span>]]</div>
| G02= <div style="float: left; text-align: left; width: 24em; padding:1em;"><br>
| G02= <div style="text-align: left; padding: 1em;"><span style="font-size:100%;color:red"> '''Avoid the use of AV node blocking agents such as digoxin, calcium channel blockers, beta blockers and adenosine.'''</span><br><br>
 
<span style="font-size:100%;color:red"> '''Avoid the use of AV node blocking agents such as digoxin, calcium channel blockers, beta blockers and adenosine.'''</span><br><br>
❑ Administer [[procainamide]], 100 mg [[infusion]] diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br>
❑ Administer [[procainamide]], 100 mg [[infusion]] diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br>
:❑ Give until the [[arrhythmia]] is suppressed or until 500 mg has been administered<br>
:❑ Give until the [[arrhythmia]] is suppressed or until 500 mg has been administered<br>
:❑ Wait 10 minutes or longer to administer new [[dosage]]
:❑ Wait 10 minutes or longer to administer new [[dosage]]
:<span style="font-size:85%;color:red">Contraindications: complete heart block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes</span><br>
:[[Contraindication|<span style="font-size:85%;color:red">Contraindications:</span>]] [[Third degree AV block|<span style="font-size:85%;color:red">third degree AV block</span>]], [[Systemic lupus erythematosus|<span style="font-size:85%;color:red">lupus erythematosus</span>]], [[Hypersensitivity|<span style="font-size:85%;color:red">idiosyncratic hypersensitivity</span>]], [[Torsades de pointes|<span style="font-size:85%;color:red">torsades de pointes</span>]]<br>
''Or''<br>❑ Administer [[ibutilide]] 1 mg IV infusion over 10 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br>
<CENTER>'''''OR'''''</CENTER>
 
❑ Administer [[ibutilide]] 1 mg IV infusion over 10 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br>
:❑ Repeat the [[dosage]] if the [[tachycardia]] continues <br>
:❑ Repeat the [[dosage]] if the [[tachycardia]] continues <br>
:<span style="font-size:85%;color:red">Contraindications: hypersensitivity to ibutilide or any component of the formulation, QTc >440 msec</span><br>
:<span style="font-size:85%;color:red">[[Contraindication|<span style="color:red">Contraindications:</span>]] [[Hypersensitivity|<span style="color:red">hypersensitivity</span>]] to [[Ibutilide|<span style="color:red">ibutilide</span>]] or any component of the formulation, [[QT interval|<span style="color:red">QTc</span>]] >440 msec</span><br>
''Or''<br>
<CENTER>'''''OR'''''</CENTER>
 
❑ Administer [[flecainide]] 50 mg every 12 hours
❑ Administer [[flecainide]] 50 mg every 12 hours
:❑ Increase 50mg BID every four days until efficacy is achieved <br>
:❑ Increase 50mg BID every four days until efficacy is achieved <br>
:❑ Maximum [[dose]] recommended for [[SVT]] is 300 mg/day<br>
:❑ Maximum [[dose]] recommended for [[SVT]] is 300 mg/day<br>
:<span style="font-size:85%;color:red">Contraindications: pre-existing second- or third-degree AV block, right bundle branch block associated with a left hemiblock unless a pacemaker is present, cardiogenic shock, hypersensitivity to the drug</span><br>
:<span style="font-size:85%;color:red">[[Contraindication|<span style="color:red">Contraindications:</span>]] pre-existing [[Second degree AV block|<span style="color:red">second degree AV block</span>]] or [[Third degree AV block|<span style="color:red">third degree AV block</span>]] , [[Right bundle brnach block|<span style="color:red">right bundle branch block</span>]] associated with a left hemiblock unless a [[Artificial pacemaker|<span style="color:red">pacemaker</span>]] is present, [[Shock|<span style="color:red">cardiogenic shock</span>]], [[Hypersensitivity|<span style="color:red">hypersensitivity</span>]] to the drug</span><br>
</div>}}
</div>}}
{{familytree/end}}
{{familytree/end}}
Line 274: Line 284:
{{familytree | | | | B01 | | B02 | | B01= '''Yes'''| B02= '''No'''}}
{{familytree | | | | B01 | | B02 | | B01= '''Yes'''| B02= '''No'''}}
{{familytree | | | | |!| | | |!| | | }}
{{familytree | | | | |!| | | |!| | | }}
{{familytree | | | | C01 | | C02 | | C01= '''Is the arrhythmia poorly tolerated, OR''' <br>'''is atrial fibrillation with rapid conduction present?'''|C02= <div style="float: left; text-align: left; width: 24em; padding:1em;">
{{familytree | | | | C01 | | C02 | | C01= '''Is the arrhythmia poorly tolerated, OR''' <br>'''is atrial fibrillation with rapid conduction present?'''|C02= <div style="text-align: left; padding: 1em;">
❑ No treatment ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]]) <br>''Or''<br>
❑ No treatment ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]]) <br><CENTER>'''''OR'''''</CENTER>
❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) </div>}}
❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) </div>}}
{{familytree | | |,|-|^|-|.| | | | | |}}
{{familytree | | |,|-|^|-|.| | | | | |}}
Line 281: Line 291:
{{familytree | | |!| | | |!| | | }}
{{familytree | | |!| | | |!| | | }}
{{familytree | | E01 | | E02 | | E01= <div style="float: left; text-align: left; width: 24em; padding:1em;"> ❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) </div>
{{familytree | | E01 | | E02 | | E01= <div style="float: left; text-align: left; width: 24em; padding:1em;"> ❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) </div>
| E02=<div style="float: left; text-align: left; width: 24em; padding:1em;">
| E02=<div style="text-align: left; padding: 1em;">
❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br>''Or''<br>
❑ [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])<br><CENTER>'''''OR'''''</CENTER>
❑ [[Antiarrhythmic agents|Class I C antiarrhythmic agents]] such as: [[flecainide]], [[propafenone]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence C]])<br>''Or''<br>
❑ [[Antiarrhythmic agents|Class I C antiarrhythmic agents]] such as: [[flecainide]], [[propafenone]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence C]])<br><CENTER>'''''OR'''''</CENTER>
❑ [[Sotalol]], [[amiodarone]] or [[beta blockers]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence C]])<br><br>
❑ [[Sotalol]], [[amiodarone]] or [[beta blockers]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence C]])<br>
<span style="font-size:100%;color:red">Avoid AV blocking agents such as: digoxin, verapamil, dialtizem</span> ([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])<br>
<span style="font-size:100%;color:red">Avoid AV blocking agents such as: digoxin, verapamil, dialtizem</span> ([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])<br>
</div> }}
</div> }}
Line 290: Line 300:


==Do's==
==Do's==
* Perform [[catheter ablation]] of the accessory pathway if possible ([[ACC AHA guidelines classification scheme|Class I, Level of evidence B]]).  
* Perform [[catheter ablation]] of the [[accessory pathway]] if possible ([[ACC AHA guidelines classification scheme|Class I, Level of evidence B]]).  
* Consider [[propafenone]] over [[flecainide]] for the prevention of recurrence of orthodromic AVRT because [[propafenone]] it has also a mild beta blocking activity.
* Consider [[propafenone]] over [[flecainide]] for the prevention of recurrence of orthodromic [[AVRT]] because [[propafenone]] it has also a mild beta blocking activity.
* Schedule [[exercise stress test]] and [[electrophysiology]] tests for the sudden cardiac death stratification ([[ACC AHA guidelines classification scheme|Class IIa, Level of evidence B]]).
* Schedule [[exercise stress test]] and [[electrophysiology]] tests for the [[sudden cardiac death]] stratification ([[ACC AHA guidelines classification scheme|Class IIa, Level of evidence B]]).
* Consider [[catheter ablation]] in asymptomatic patients with structural heart disease ([[ACC AHA guidelines classification scheme|Class IIb, Level of evidence C]]).
* Consider [[catheter ablation]] in [[asymptomatic]] patients with [[structural heart disease]] ([[ACC AHA guidelines classification scheme|Class IIb, Level of evidence C]]).
* Administer IV [[procainamide]] ([[ACC AHA guidelines classification scheme|Class I, Level of evidence C]]), [[ibutilide]] ([[ACC AHA guidelines classification scheme|Class I, Level of evidence C]]) or [[flecainide]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of evidence B]]) among [[WPW syndrome]] patients who present with [[atrial fibrillation]] .  Intravenous [[quinidine]], [[procainamide]], [[disopyramide]], [[ibutilide]], or [[amiodarone]] can also be considered ([[ACC AHA guidelines classification scheme|Class IIb, Level of evidence B]]).<ref name="pmid23545139">{{cite journal| author=American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB et al.| title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 18 | pages= 1916-26 | pmid=23545139 | doi=10.1161/CIR.0b013e318290826d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23545139  }} </ref>
* Administer IV [[procainamide]] ([[ACC AHA guidelines classification scheme|Class I, Level of evidence C]]), [[ibutilide]] ([[ACC AHA guidelines classification scheme|Class I, Level of evidence C]]) or [[flecainide]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of evidence B]]) among [[WPW syndrome]] patients who present with [[atrial fibrillation]] .  Intravenous [[quinidine]], [[procainamide]], [[disopyramide]], [[ibutilide]], or [[amiodarone]] can also be considered ([[ACC AHA guidelines classification scheme|Class IIb, Level of evidence B]]).<ref name="pmid23545139">{{cite journal| author=American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB et al.| title=Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 18 | pages= 1916-26 | pmid=23545139 | doi=10.1161/CIR.0b013e318290826d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23545139  }} </ref>


==Don'ts==
==Don'ts==
* Don't use AV blocking agents in patients with [[WPW]] and antidromic AVRT as it will promote conduction down the accessory pathway ([[ACC AHA guidelines classification scheme|Class III, Level of evidence C]]).<ref name="Garratt-1989">{{Cite journal  | last1 = Garratt | first1 = C. | last2 = Antoniou | first2 = A. | last3 = Ward | first3 = D. | last4 = Camm | first4 = AJ. | title = Misuse of verapamil in pre-excited atrial fibrillation. | journal = Lancet | volume = 1 | issue = 8634 | pages = 367-9 | month = Feb | year = 1989 | doi =  | PMID = 2563516 }}</ref><ref name="Gulamhusein-1982">{{Cite journal  | last1 = Gulamhusein | first1 = S. | last2 = Ko | first2 = P. | last3 = Carruthers | first3 = SG. | last4 = Klein | first4 = GJ. | title = Acceleration of the ventricular response during atrial fibrillation in the Wolff-Parkinson-White syndrome after verapamil. | journal = Circulation | volume = 65 | issue = 2 | pages = 348-54 | month = Feb | year = 1982 | doi =  | PMID = 7053894 }}</ref><ref name="McGovern-1986">{{Cite journal  | last1 = McGovern | first1 = B. | last2 = Garan | first2 = H. | last3 = Ruskin | first3 = JN. | title = Precipitation of cardiac arrest by verapamil in patients with Wolff-Parkinson-White syndrome. | journal = Ann Intern Med | volume = 104 | issue = 6 | pages = 791-4 | month = Jun | year = 1986 | doi =  | PMID = 3706931 }}</ref>
* Don't administer AV blocking agents in patients with [[WPW]] and antidromic AVRT as it will promote conduction down the accessory pathway ([[ACC AHA guidelines classification scheme|Class III, Level of evidence C]]).<ref name="Garratt-1989">{{Cite journal  | last1 = Garratt | first1 = C. | last2 = Antoniou | first2 = A. | last3 = Ward | first3 = D. | last4 = Camm | first4 = AJ. | title = Misuse of verapamil in pre-excited atrial fibrillation. | journal = Lancet | volume = 1 | issue = 8634 | pages = 367-9 | month = Feb | year = 1989 | doi =  | PMID = 2563516 }}</ref><ref name="Gulamhusein-1982">{{Cite journal  | last1 = Gulamhusein | first1 = S. | last2 = Ko | first2 = P. | last3 = Carruthers | first3 = SG. | last4 = Klein | first4 = GJ. | title = Acceleration of the ventricular response during atrial fibrillation in the Wolff-Parkinson-White syndrome after verapamil. | journal = Circulation | volume = 65 | issue = 2 | pages = 348-54 | month = Feb | year = 1982 | doi =  | PMID = 7053894 }}</ref><ref name="McGovern-1986">{{Cite journal  | last1 = McGovern | first1 = B. | last2 = Garan | first2 = H. | last3 = Ruskin | first3 = JN. | title = Precipitation of cardiac arrest by verapamil in patients with Wolff-Parkinson-White syndrome. | journal = Ann Intern Med | volume = 104 | issue = 6 | pages = 791-4 | month = Jun | year = 1986 | doi =  | PMID = 3706931 }}</ref>
* Avoid the usage of AV blocking agents in patients with [[WPW]] and [[AF]] ([[ACC AHA guidelines classification scheme|Class III, Level of evidence B]]).<br>
* Don't administer AV blocking agents in patients with [[WPW]] and [[AF]] ([[ACC AHA guidelines classification scheme|Class III, Level of evidence B]]).<br>
* Avoid AV blocking agents (such as [[digoxin]], [[verapamil]] or [[diltiazem]]) in the chronic treatment of [[WPW syndrome]] to prevent the recurrence of tachycardia ([[ACC AHA guidelines classification scheme|Class III, Level of evidence B]]).<br>
* Don't administer AV blocking agents (such as [[digoxin]], [[verapamil]] or [[diltiazem]]) in the chronic treatment of [[WPW syndrome]] to prevent the recurrence of tachycardia ([[ACC AHA guidelines classification scheme|Class III, Level of evidence B]]).<br>


==References==
==References==

Latest revision as of 02:42, 26 October 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2]; Hilda Mahmoudi M.D., M.P.H.[3]; Alejandro Lemor, M.D. [4]

Wolff-Parkinson-White Syndrome Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagsis
Treatment
Initial
Long-term
Do's
Don'ts

Overview

Wolff-Parkinson-White (WPW) syndrome is a condition of pre-excitation of the ventricles of the heart due to the presence of an accessory pathway known as the Bundle of Kent through which the electrical impulses bypass the AV node. The difference between WPW pattern and WPW syndrome is that WPW pattern is characterized by the presence of characteristic ECG findings, such as a short PR interval and a delta wave, whereas WPW syndrome is the occurrence of tachycardia with or without associated symptoms in a subject with existing WPW pattern.[1] The treatment of WPW syndrome is targeted towards the restoration of the sinus rhythm, usually by the administration of either ibutilide or procainamide. The most common type of arrhythmia in WPW syndrome is AV reentrant tachycardia.[2] Atrial fibrillation in a patient with WPW is life threatening and should be managed urgently. Atrial fibrillation in a patient with WPW should be suspected when there is ECG findings suggestive of atrial fibrillation in the context of a heart rate higher than 220 beats per minute.

Causes

Life Threatening Causes

Wolff-Parkinson-White syndrome can be a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[2][3]
Boxes in red signify that an urgent management is needed.

Abbreviations: AF: atrial fibrillation; AVRT: AV reentrant tachycardia; BP: blood pressure; ECG: electrocardiography; HF: heart failure; LVH: left ventricular hypertrophy; WPW: Wolff-Parkinson-White pattern

 
 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of Wolff-Parkinson-White syndrome

❑ Baseline ECG findings suggestive of WPW pattern (pre-excitation)

PR interval (<120 ms)
Delta wave
   

AND
Tachyarrhythmia

ECG findings suggestive of orthodromic AVRT

❑ Ventricular rate usually 200–300 bpm
❑ Regular, narrow QRS complex (usually <120 ms unless pre-existing bundle branch block or aberrant conduction)
P waves may be buried in the QRS or retrograde
Delta wave may be lost during NSR in case of participating concealed bypass tract

ECG findings suggestive of antidromic AVRT

❑ Ventricular rate usually 200–300 bpm
❑ Regular, wide QRS complex
Delta wave is observed during NSR

ECG findings suggestive of AF with WPW

❑ Ventricular rate usually >200 bpm
❑ Irregularly irregular, wide QRS complex with varying morphology
❑ Absence of P waves
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings that require urgent cardioversion?

❑ Hemodynamic instability

Hypotension
Cold extremities
Peripheral cyanosis
Mottling
Altered mental status

Chest discomfort suggestive of ischemia

Decompensated heart failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
NO
 
 
 
 
 
 
 
Perform
electrical cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Irregular wide QRS complex

❑ Unsynchronized, biphasic 120–200 J OR
❑ Unsynchronized, monophasic 360 J

Irregular narrow QRS complex

❑ Synchronized, biphasic 120–200 J OR
❑ Synchronized, monophasic 200 J

Regular wide QRS complex

❑ Synchronized, biphasic or monophasic 100 J

Regular narrow QRS complex

❑ Synchronized, biphasic or monophasic 50–100 J
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[2]

Abbreviations: AF: atrial fibrillation; AVRT: AV reentrant tachycardia; BP: blood pressure; ECG: electrocardiography; HF: heart failure; LVH: left ventricular hypertrophy

 
 
 
 
Characterize the symptoms:

Asymptomatic
Palpitations
Dyspnea
Fatigue
Chest discomfort
Lightheadedness
Polyuria
Characterize the timing of the symptoms:
❑ Onset

❑ First episode
❑ Recurrent

❑ Duration
❑ Frequency
❑ Termination of the episode

❑ Spontaneous
Medication use
❑ Not terminated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Appearance of the patient
❑ Cool and diaphoretic

Vitals
Heart rate

Tachycardia (150-250 beats per minute)
Rhythm
❑ Regular (most of the cases)
❑ Irregularly irregular (suggestive of AF)

Blood pressure

Hypotension
❑ Normal BP

Cardiovascular
❑ Normal heart examination in most cases
Tricuspid regurgitation characterized by a holosystolic murmur heard best along the left lower sternal border (suggestive of Ebstein's anomaly)
S4 (suggestive of LVH)

Respiratory
Rales (suggestive of HF)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
WPW with AF

❑ Suspect when AF appears with heart rates of 220 to 360
❑ Irregularly irregular, wide QRS complex with varying morphology

❑ Absence of P waves[4]
 
Orthodromic AVRT

❑ Ventricular rate usually 200–300 bpm
❑ Regular, narrow QRS complex (usually <120 ms unless pre-existing bundle branch block or aberrant conduction)
P waves may be buried in the QRS or retrograde
Delta wave may be lost during NSR in case of participating concealed bypass tract

 
Antidromic AVRT

❑ Ventricular rate usually 200–300 bpm
❑ Regular, wide QRS complex
Delta wave is observed during NSR

 
 

Treatment

Initial Treatment

Shown below is an algorithm summarizing the initial approach to Wolff-Parkinson-White syndrome according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias.[2][3]

 
 
 
Does the patient have any of the following findings that require urgent cardioversion?

❑ Hemodynamic instability

Hypotension
Cold extremities
Peripheral cyanosis
Mottling
Altered mental status

Chest discomfort suggestive of ischemia
Decompensated heart failure

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Direct current cardioversion (Urgent)
Check FIRE for details
 
 
 
What is the type of tachycardia according to the ECG findings?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
WPW + AF (Stable)
 
Orthodromic AVRT (Stable)
 
Antidromic AVRT (Stable)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Avoid the use of AV node blocking agents such as digoxin, calcium channel blockers, beta blockers and adenosine.

❑ Administer procainamide, 100 mg infusion diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes (Class I, Level of Evidence C)[5]

❑ Administer until the arrhythmia is suppressed or until 500 mg has been administered
❑ Wait 10 minutes or longer to administer new dosage
Contraindications: third degree AV block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes
OR

❑ Administer ibutilide 1 mg IV infusion over 10 minutes (Class I, Level of Evidence C)[5]

❑ Repeat the dosage if the tachycardia continues
Contraindications: hypersensitivity to ibutilide or any component of the formulation, QTc >440 msec
OR

❑ Administer flecainide 50 mg every 12 hours (Class IIa, Level of Evidence B)[5]

❑ Increase 50mg BID every four days until efficacy is achieved
❑ Maximum dose recommended for SVT is 300 mg/day
Contraindications: pre-existing second degree AV block or third degree AV block , right bundle branch block associated with a left hemiblock unless a pacemaker is present, cardiogenic shock, hypersensitivity to the drug
 
❑ Use vagal maneuvers (Class I, Level of Evidence B)
Carotid sinus massage
Valsalva maneuver


If not effective initiate IV AV nodal blocking agent

❑ Administer adenosine 6 mg IV (bolus) (Class I, Level of Evidence A)

❑ If initial dose is not effective, administer a second dose of 12 mg, repeated a second time if required
Contraindications: second degree AV block or third degree AV block unless a pacemaker is present

If not effective

❑ Administer verapamil 5 to 10 mg (0.075 to 0.15 mg/kg body weight) IV boluses of over 2 minutes (Class I, Level of Evidence A)

❑ Give 30% of the dose in case of hepatic impairment
❑ Monitor for prolonged PR interval in case of renal impairment
Contraindications: severe left ventricular dysfunction, hypotension or cardiogenic shock

If not effective

❑ Administer procainamide, 100 mg infusion diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes (Class I, Level of Evidence B)

❑ Give until the arrhythmia is suppressed or up to 500 mg
❑ Wait 10 minutes or longer to administer new dosage
Dosage should be adjusted for the individual patient in case of renal impairment
Contraindications: third degree AV block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes
 
Avoid the use of AV node blocking agents such as digoxin, calcium channel blockers, beta blockers and adenosine.

❑ Administer procainamide, 100 mg infusion diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes (Class I, Level of Evidence B)

❑ Give until the arrhythmia is suppressed or until 500 mg has been administered
❑ Wait 10 minutes or longer to administer new dosage
Contraindications: third degree AV block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes
OR

❑ Administer ibutilide 1 mg IV infusion over 10 minutes (Class I, Level of Evidence B)

❑ Repeat the dosage if the tachycardia continues
Contraindications: hypersensitivity to ibutilide or any component of the formulation, QTc >440 msec
OR

❑ Administer flecainide 50 mg every 12 hours

❑ Increase 50mg BID every four days until efficacy is achieved
❑ Maximum dose recommended for SVT is 300 mg/day
Contraindications: pre-existing second degree AV block or third degree AV block , right bundle branch block associated with a left hemiblock unless a pacemaker is present, cardiogenic shock, hypersensitivity to the drug
 
 
 

Long-Term Treatment

Shown below is an algorithm summarizing the long-term treatment of Wolff-Parkinson-White syndrome.[2]

 
 
 
 
 
Does the patient with pre-excitation have symptomatic arrhythmia?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the arrhythmia poorly tolerated, OR
is atrial fibrillation with rapid conduction present?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

Don'ts

References

  1. "Wolff-Parkinson-White Syndrome and Accessory Pathways". Retrieved 1 April 2014.
  2. 2.0 2.1 2.2 2.3 2.4 "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.
  3. 3.0 3.1 "Part 8: Adult Advanced Cardiovascular Life Support". Retrieved 3 April 2014.
  4. Fengler, Brian T.; Brady, William J.; Plautz, Claire U. (2007). "Atrial fibrillation in the Wolff-Parkinson-White syndrome: ECG recognition and treatment in the ED". The American Journal of Emergency Medicine. 25 (5): 576–583. doi:10.1016/j.ajem.2006.10.017. ISSN 0735-6757.
  5. 5.0 5.1 5.2 5.3 American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB; et al. (2013). "Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines". Circulation. 127 (18): 1916–26. doi:10.1161/CIR.0b013e318290826d. PMID 23545139.
  6. Garratt, C.; Antoniou, A.; Ward, D.; Camm, AJ. (1989). "Misuse of verapamil in pre-excited atrial fibrillation". Lancet. 1 (8634): 367–9. PMID 2563516. Unknown parameter |month= ignored (help)
  7. Gulamhusein, S.; Ko, P.; Carruthers, SG.; Klein, GJ. (1982). "Acceleration of the ventricular response during atrial fibrillation in the Wolff-Parkinson-White syndrome after verapamil". Circulation. 65 (2): 348–54. PMID 7053894. Unknown parameter |month= ignored (help)
  8. McGovern, B.; Garan, H.; Ruskin, JN. (1986). "Precipitation of cardiac arrest by verapamil in patients with Wolff-Parkinson-White syndrome". Ann Intern Med. 104 (6): 791–4. PMID 3706931. Unknown parameter |month= ignored (help)


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