Wolff-Parkinson-White syndrome medical therapy: Difference between revisions

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{{Wolff-Parkinson-White syndrome}}
{{Wolff-Parkinson-White syndrome}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}; {{Rim}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{Sara.Zand}} {{CZ}}; {{Rim}}


==Overview==
==Overview==


Wolff-Parkinson-White (WPW) syndrome patients who are hemodynamically unstable, as reflected by the presence of [[hypotension]], [[cold extremities]], [[mottling]] or [[peripheral cyanosis]], or those who present with ischemic [[chest pain]] or decompensated [[heart failure]] should urgently undergo direct current cardioversion.<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>  The medical therapy of hemodynamically stable patients with WPW syndrome depends on the type of the [[tachycardia]].  When the [[ECG]] findings suggest orthodromic [[AVRT]], the patient should be managed similarly to patients with [[SVT|supreventricular tachycardia]] followed by the sequential administration of [[adenosine]], [[verapamil]] and [[procainamide]] in case of failure to improve.  Among patients with antidromic [[AVRT]], [[AV node|AV nodal]] blocking agents should be avoided and patients should be treated with either [[procainamide]], [[ibutilide]] or [[flecainide]].<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>  In case of WPW syndrome with [[atrial fibrillation]] in hemodynamically stable patients, [[procainamide]], [[ibutilide]] or [[flecainide]] can be administered.<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>  The long term treatment of patients with WPW syndrome depends on the presence or absence of [[symptoms]] and their severity.  Patients who have poorly tolerated symptomatic WPW syndrome should undergo [[catheter ablation.<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>
[[Wolff-Parkinson-White syndrome]] patients who are hemodynamically unstable, as reflected by the presence of [[hypotension]], [[cold extremities]], [[mottling]] or [[peripheral cyanosis]], or those who present with ischemic [[chest pain]] or decompensated [[heart failure]] should urgently undergo direct current cardioversion. The medical therapy of hemodynamically stable patients with [[WPW]] syndrome depends on the type of the [[tachycardia]].  When the [[ECG]] findings suggest orthodromic [[AVRT]], the patient should be managed similarly to patients with [[SVT|supreventricular tachycardia]] followed by the sequential administration of [[adenosine]], [[verapamil]] and [[procainamide]] in case of failure to improve.  Among patients with antidromic [[AVRT]], [[AV node|AV nodal]] blocking agents should be avoided and patients should be treated with either [[procainamide]], [[ibutilide]] or [[flecainide]]. The long term treatment of patients with [[WPW]] syndrome depends on the presence or absence of [[symptoms]] and their severity.  Patients who have poorly tolerated symptomatic [[WPW syndrome]] should undergo [[catheter ablation.


==Acute Treatment==
==Acute Treatment==
===Atrioventricular Reentrant Tachycardia (AVRT)===
===Atrioventricular Reentrant Tachycardia (AVRT)===
* AVRT is one of the type of [[tachycardia]] that can occur in patients with WPW pattern.  AVRT can be either orthodromic or antidromic, and the distinction between the two types is important because it dictates the choice of treatment.
* [[AVRT]] is one of the type of [[tachycardia]] that can occur in patients with [[WPW]] pattern.   
*[[ AVRT]] can be either orthodromic or antidromic and the treatment of them is different.
====Hemodynamically Unstable Patients====
====Hemodynamically Unstable Patients====
* WPW syndrome patients with [[AVRT]] who are hemodynamically unstable, as reflected by the presence of [[hypotension]], [[cold extremities]], [[mottling]] or [[peripheral cyanosis]], or those who present with ischemic [[chest pain]] or decompensated [[heart failure]] should urgently undergo direct current cardioversion.  The shocks should be delivered as follows:
:* [[WPW]] syndrome patients with [[AVRT]] who are hemodynamically unstable,should urgently undergo [[direct current cardioversion]]
:* The signs of instability of hemodynamic include the following:
* [[hypotension]],
* [[cold extremities]]  
* [[mottling]]  
* [[peripheral cyanosis]]  
* [[chest pain]]
* decompensated [[heart failure]]
** The shocks should be delivered as follows:
** Narrow regular rhythm: synchronized electrical cardioversion, 50-100 Joules
** Narrow regular rhythm: synchronized electrical cardioversion, 50-100 Joules
** Narrow irregular rhythm: synchronized electrical cardioversion, 120-200 Joules biphasic or 200 Joules monophasic
** Narrow irregular rhythm: synchronized electrical cardioversion, 120-200 Joules biphasic or 200 Joules monophasic
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** Wide irregular rhythm: unsynchronized electrical cardioversion, 200-360 Joules monophasic, or 100-200 Joules biphasic<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>
** Wide irregular rhythm: unsynchronized electrical cardioversion, 200-360 Joules monophasic, or 100-200 Joules biphasic<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>


====Orthodromic AVRT in Hemodynamically Stable Patients====
====Orthodromic [[AVRT]] in Hemodynamically Stable Patients====
* The management of WPW syndrome patients who are hemodynamically stable depends on the type of [[AVRT]]. When the [[ECG]] findings suggest orthodromic [[AVRT]], the patient should be managed similarly to patients with [[SVT|supreventricular tachycardia]]. The management should begin with [[vagal maneuvers]] such as [[carotid sinus massage]] and [[valsalva maneuver]]. If the patient's tachycardia does not resolve, the patient should be administered IV [[adenosine]]. In case of failure to improve, administration of [[verapamil]] must be considered followed by [[procainamide]].<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>
* The management of [[WPW syndrome]] patients who are hemodynamically stable depends on the type of [[AVRT]].  
* When the [[ECG]] findings suggest orthodromic [[AVRT]] and [[QRS]] complex is narrow, the patient should be managed similarly to patients with [[SVT|supreventricular tachycardia]].
* The management should begin with [[vagal maneuvers]] such as [[carotid sinus massage]] and [[valsalva maneuver]].  
* If the patient's tachycardia does not resolve, the patient should be administered IV [[adenosine]].  
* In case of failure to improve, administration of [[ibutilide ]] may be considered followed by [[procainamide]]


The sequence of therapeutic decisions is summarized below.
The sequence of therapeutic decisions is summarized below.<ref name="PageJoglar2016">{{cite journal|last1=Page|first1=Richard L.|last2=Joglar|first2=José A.|last3=Caldwell|first3=Mary A.|last4=Calkins|first4=Hugh|last5=Conti|first5=Jamie B.|last6=Deal|first6=Barbara J.|last7=Estes III|first7=N.A. Mark|last8=Field|first8=Michael E.|last9=Goldberger|first9=Zachary D.|last10=Hammill|first10=Stephen C.|last11=Indik|first11=Julia H.|last12=Lindsay|first12=Bruce D.|last13=Olshansky|first13=Brian|last14=Russo|first14=Andrea M.|last15=Shen|first15=Win-Kuang|last16=Tracy|first16=Cynthia M.|last17=Al-Khatib|first17=Sana M.|title=2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia|journal=Heart Rhythm|volume=13|issue=4|year=2016|pages=e136–e221|issn=15475271|doi=10.1016/j.hrthm.2015.09.019}}</ref>


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❑ [[Carotid sinus massage]] for 5-10 seconds in the absent of bruit <br>
❑ [[Carotid sinus massage]] for 5-10 seconds in the absence of bruit <br>
❑ [[Valsalva maneuver]] for 10-30 seconds by bearing down against closed glottis,more successful technique<br>
❑ [[Valsalva maneuver]] for 10-30 seconds by bearing down against closed glottis, a more successful technique<br>
❑ Applying ice-cold wet towel to the face<br>
❑ Applying ice-cold wet towel to the face<br>
|-
|-
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<span style="font-size:85%;color:red">[[Contraindication|<span style="color:red">Contraindications:</span>]] [[asthma|<span style="color:red">asthma,</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>
<span style="font-size:85%;color:red">[[Contraindication|<span style="color:red">Contraindications:</span>]] [[asthma|<span style="color:red">asthma,</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>
|-
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Synchronized cardioversion]] in [[unstable hemodynamic]] and ineffectiveness of [[vagal maneuver]] or adenosin: ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Synchronized cardioversion]] : ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|❑ Highly effective in termination of AVRT<br>
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|❑ Highly effective in termination of AVRT<br>
❑ In [[unstable hemodynamic]] or stable hemodynamic and ineffectiveness of [[vagal maneuver]] or adenosine is recommended<br>
❑ Avoidance of complications associated [[antiarrhythmic]] drugs <br>
❑ Avoidance of complications associated [[antiarrhythmic]] drugs <br>
❑ In the presence of [[PVC]] or [[PAC]]  just after [[cardioversion]], [[antiarrhythmic]] drugs is recommended for prevention of restarting [[AVRT]] <br>
❑ In the presence of [[PVC]] or [[PAC]]  just after [[cardioversion]], [[antiarrhythmic]] drugs is recommended for prevention of restarting [[AVRT]] <br>
❑ In the  presence of hemodynamically  unstable and pre excited [[AF]], [[synchronized cardioversion]] is recommended
|-
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''If verapamil is not effective:'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Ibutilide]] or intravenous [[procainamide]]:([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|❑ 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>
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
Give until the [[arrhythmia]] is suppressed or up to 500 mg <br>
effective in hemodynamic stable and preexcited [[AF]] by slowing conduction over the [[accessory pathway]]<br>
❑ Wait 10 minutes or longer to administer new dosage <br>
<span style="font-size:85%;color:red"> [[Contraindication|<span style="color:red">Contraindications:</span>]] [[Compromised left ventricular function|<span style="color:red">Compromised left ventricular function</span>]]
❑ Dosage should be adjusted for the individual patient in case of [[renal impairment]] <br>
<br>
<span style="font-size:85%;color:red"> [[Contraindication|<span style="color:red">Contraindications:</span>]] [[Third degree AV block|<span style="color:red">third degree AV block</span>]], [[Systemic lupus erythematosus|<span style="color:red">lupus erythematosus</span>]], [[Hypersensitivity|<span style="color:red">idiosyncratic hypersensitivity</span>]], [[Torsades de pointes|<span style="color:red">torsades de pointes</span>]] </span>
<br>OR <br>
❑ Administer [[propranolol]], [[metoprolol]], and [[esmolol]
|}
 
 
 
 
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for acute treatment of orthodromic AVRT'''
|-
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Perform the following maneuvers ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Intravenous diltiazem,verapamil ,beta blockers]] : ([[ACC AHA guidelines classification scheme|Class 2a, Level of Evidence B-C]])'''
|-
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|❑ [[Vagal maneuver]]s <br>
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Carotid sinus massage]] <br>
Effective for acute treatment of orthodromic [[AVRT]] without pre-excitation on resting [[ECG]] during [[sinus rhythm]](LOR=B)<br>
❑ [[Valsalva maneuver]] <br>
Intravenous [[ diltiazem]] or [[verapamil]]  effectively terminate  90% to 95% of [[AVRT]] without [[pre-excitation]] on their resting [[sinus-rhythm]] [[ECG]]<br>
Hypotension may occur in 3% patients receiving Intravenous [[diltiazem]] or [[verapamil]] <br>
❑ Intravenous [[beta blocker]] are effective for terminating [[AVRT]] with low risk of associated complications(LOR=C)<br>
|-
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''If not effective initiate the IV AV nodal blocking agent adenosine:'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Intravenous [[betablockers]],[[diltiazem]],[[verapamil]] ([[ACC AHA guidelines classification scheme|Class 2b, Level of Evidence B]]):'''
|-
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|❑ Administer [[adenosine]] 6 mg IV (bolus) ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]]) <br>
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
If the initial dose is not effective, administer a second dose of 12 mg, repeated a second time if required<br>
Acute termination of orthodromic [[AVRT]] with [[pre-excitation]] on resting [[ECG]] without response to other treatment<br>
<span style="font-size:85%;color:red">[[Contraindication|<span style="color:red">Contraindications:</span>]] [[asthma|<span style="color:red">asthma,</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>
The complication is enhancing conduction over the [[accessory pathway]] if the [[AVRT]] converts to [[ AF]] during the administration of the medication<br>
|-
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''If adenosine is not effective:'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intravenous [[digoxin]],intravenous [[amiodarone]],intravenous or oral [[beta blockers]],[[diltiazem]],[[verapamil]] : ([[ACC AHA guidelines classification scheme|Class 3, Harm, Level of Evidence B]])'''
|-
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|❑ Administer [[verapamil]] 5 to 10 mg (0.075 to 0.15 mg/kg body weight) IV boluses of over 2 minutes ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]]) <br>
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
Give 30% of the dose in case of [[hepatic impairment]] <br>
Harmful in acute termination of peexcitated [[AF]] due to increased risk of [[ventricular fibrillation]] by these mechanisms: <br>  
❑ Monitor for prolonged PR interval in case of [[renal impairment]] <br>
Increased conduction over the [[accessory pathway]] and slowing or blocking conduction over [[AV node]] <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>
Deceased [[refractory period]] of [[accessory pathway]] by [[digoxin]]<br>
|-
Increased cathecolamin due to drug induced [[hypotension]] such as  [[amiodarone]], [[beta blocker]], [[verapamil]], [[diltiazem]]<br>
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''If verapamil is not effective:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|❑ 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 up to 500 mg <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>
<span style="font-size:85%;color:red"> [[Contraindication|<span style="color:red">Contraindications:</span>]] [[Third degree AV block|<span style="color:red">third degree AV block</span>]], [[Systemic lupus erythematosus|<span style="color:red">lupus erythematosus</span>]], [[Hypersensitivity|<span style="color:red">idiosyncratic hypersensitivity</span>]], [[Torsades de pointes|<span style="color:red">torsades de pointes</span>]] </span>
<br>OR <br>
Administer [[propranolol]], [[metoprolol]], and [[esmolol]]
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''If verapamil is not effective:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|❑ 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 up to 500 mg <br>
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''If verapamil is not effective:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|❑ 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 up to 500 mg <br>
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''If verapamil is not effective:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|❑ 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 up to 500 mg <br>
|}
|}


====Antidromic AVRT in Hemodynamically Stable Patients====
====Antidromic AVRT in Hemodynamically Stable Patients====
* In antidromic AVRT, the antegrade conduction of the electrical signals occurs through the accessory pathway, while the retrograde conduction occurs through either the [[AV node]] or a second [[accessory pathway]]. Therefore, among patients with antidromic [[AVRT]], [[AV node|AV nodal]] blocking agents should be avoided because they are ineffective in the subset of patients among whom the retrograde conduction occurs through a second [[accessory pathway]] rather than through the [[AV node]]In this case, the use of [[digoxin]], [[calcium channel blockers]], [[beta blockers]] and [[adenosine]] should be avoided.  [[Adenosine]], in particular, might lead to [[atrial fibrillation]] with rapid ventricular response.  Patients should be treated with either [[procainamide]], [[ibutilide]], or [[flecainide]].<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>
* In antidromic AVRT, the antegrade conduction of the electrical signals occurs through the [[accessory pathway]], while the retrograde conduction occurs through either the [[AV node]] or a second [[accessory pathway]].<ref name="PageJoglar2016">{{cite journal|last1=Page|first1=Richard L.|last2=Joglar|first2=José A.|last3=Caldwell|first3=Mary A.|last4=Calkins|first4=Hugh|last5=Conti|first5=Jamie B.|last6=Deal|first6=Barbara J.|last7=Estes III|first7=N.A. Mark|last8=Field|first8=Michael E.|last9=Goldberger|first9=Zachary D.|last10=Hammill|first10=Stephen C.|last11=Indik|first11=Julia H.|last12=Lindsay|first12=Bruce D.|last13=Olshansky|first13=Brian|last14=Russo|first14=Andrea M.|last15=Shen|first15=Win-Kuang|last16=Tracy|first16=Cynthia M.|last17=Al-Khatib|first17=Sana M.|title=2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia|journal=Heart Rhythm|volume=13|issue=4|year=2016|pages=e136–e221|issn=15475271|doi=10.1016/j.hrthm.2015.09.019}}</ref>
*  In antidromic [[AVRT]], [[AV node|AV nodal]] blocking agents should be avoided.  
* [[Digoxin]], [[calcium channel blockers]], [[beta blockers]] and [[adenosine]] should be avoided.  
* [[Adenosine]] may lead to [[atrial fibrillation]] with rapid ventricular response.   
[[Procainamide]] or [[ibutilide]] are recommended .


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| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=left |❑ Repeat the dosage if the [[tachycardia]] continues <br>
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=left |❑ Repeat the dosage if the [[tachycardia]] continues <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>
<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>
|-
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=left |[[Flecainide]]
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=left |  50 mg every 12 hours
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=left |❑ Increase 50mg BID every four days until efficacy is achieved <br>
❑ Maximum dose recommended for [[supraventricular tachycardia]] is 300 mg/day <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 branch 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>
|}
|}


===Atrial Fibrillation===
===Atrial Fibrillation===
* WPW syndrome with [[atrial fibrillation]] should be suspected whenever the [[ECG]] reveals an irregular rhythm with absent [[P wave]] in the presence of a [[heart rate]] more than 220 beats per minute.
* WPW syndrome with [[atrial fibrillation]] should be suspected whenever the [[ECG]] reveals an irregular rhythm with absent [[P wave]] in the presence of a [[heart rate]] more than 240 beats per minute.


====Hemodynamically Unstable Patients====
====Hemodynamically Unstable Patients====
In hemodynamically unstable patients, urgent [[direct current cardioversion]] should be performed.<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>
In hemodynamically unstable patients, urgent [[direct current cardioversion]] should be performed.<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>
====Hemodynamically Stable Patients====
* Hemodynamically stable patients can be administered any of the following intravenous medications:
** [[Procainamide]] ([[ACC AHA guidelines classification scheme|Class I, Level of evidence C]])- in the presence of [[wide QRS]] on ECG or a rapid preexcited ventricular response
** [[Ibutilide]] ([[ACC AHA guidelines classification scheme|Class I, Level of evidence C]])- in the presence of [[wide QRS]] on ECG or a rapid preexcited ventricular response
** [[Flecainide]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of evidence B]])
** [[Quinidine]] ([[ACC AHA guidelines classification scheme|Class IIb, Level of evidence B]])
** [[Procainamide]] ([[ACC AHA guidelines classification scheme|Class IIb, Level of evidence B]])
** [[Disopyramide]] ([[ACC AHA guidelines classification scheme|Class IIb, Level of evidence B]])
** [[Ibutilide]] ([[ACC AHA guidelines classification scheme|Class IIb, Level of evidence B]])
** [[Amiodarone]]([[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>
* AV nodal blocking drugs, such as [[adenosine]], [[verapamil]], [[digoxin]], and [[beta blockers]] must be avoided.


==Long Term Treatment==
==Long Term Treatment==
The long term management of patients with WPW syndrome depends on the presence or absence of syndrome.  Among symptomatic patients, the tolerability of the symptoms guides the choice of the long term treatment.<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>
'''Management of patients with [[AVRT]] includes the following:'''<ref name="PageJoglar2016">{{cite journal|last1=Page|first1=Richard L.|last2=Joglar|first2=José A.|last3=Caldwell|first3=Mary A.|last4=Calkins|first4=Hugh|last5=Conti|first5=Jamie B.|last6=Deal|first6=Barbara J.|last7=Estes III|first7=N.A. Mark|last8=Field|first8=Michael E.|last9=Goldberger|first9=Zachary D.|last10=Hammill|first10=Stephen C.|last11=Indik|first11=Julia H.|last12=Lindsay|first12=Bruce D.|last13=Olshansky|first13=Brian|last14=Russo|first14=Andrea M.|last15=Shen|first15=Win-Kuang|last16=Tracy|first16=Cynthia M.|last17=Al-Khatib|first17=Sana M.|title=2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia|journal=Heart Rhythm|volume=13|issue=4|year=2016|pages=e136–e221|issn=15475271|doi=10.1016/j.hrthm.2015.09.019}}</ref>


===Asymptomatic Patients===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
* Asymptomatic patients can either receive no treatment ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]]) or can undergo [[catheter ablation]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]).<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>
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for longterm  treatment of orthodromic AVRT'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Catheter ablation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Successful rate of ablation for [[AF]]+ [[AVRT]] is 93-95% <br>
❑ In young patients, the risk of recurrent [[AF]] after ablation of the accessory pathway is low<br>
❑ Recurrence of [[ AF]] in older patients after ablation may be related to other causes<br>
❑ Successful rate of ablation for [[mahain]] [[accessory pathway]] is 70-100%<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Oral [[beta blockers]], [[diltiazem]], [[verapamil]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Effective in patients without preexcitation in resting [[ECG]]<br>
❑ Prevention of [[AVRT]] recurrence in 50% patients<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Oral [[flecainide]] or [[propafenone]] ([[ACC AHA guidelines classification scheme|Class 2a, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑  For [[patients]] with [[AVRT]] and/or pre-excited [[AF]] that are not candidates or do not prefer [[catheter ablation]]<br>
❑ Mechanism of action is slowing or blocking conduction over the [[accessory pathway]]<br>
❑ Contraindications are ischemic or [[structural heart disease]] due to increased risk of [[VT]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Oral dofetilide or sotalol ([[ACC AHA guidelines classification scheme|Class 2b, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑  For patients with [[AVRT]] and/or pre-excited [[AF]] that are not candidated or do not prefer catheter ablation<br>
❑ Be useful in patients with structural heart disease or coronary artery disease<br>
❑ Side effect is [[QT ]] prolongation and [[torsades de poites]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Oral amiodarone ([[ACC AHA guidelines classification scheme|Class 2b, Level of Evidence C ]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ For [[patients]] with [[AVRT]] and/or pre-excited [[AF]] that are not candidated or do not prefer catheter ablation<br>
❑ For [[patients]] that using [[betablocker]], [[diltiazem]] or [[verapamil]] and [[flecainide]] are contraindicated or ineffective <br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Oral [[beta blockers]], [[diltiazem]], [[verapamil]] ([[ACC AHA guidelines classification scheme|Class 2b, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For patients with [[AVRT]] and/or pre-excited [[AF]] that are not candidates or do not prefer catheter ablation<br>
❑ Due to the risk of developing rapid [[AF]] in [[AVRT]], these drugs should be used with causion<br>
❑ Only one RCT supported  the use of [[verapamil]] for the prevention of orthodromic [[AVRT]] in patients with pre-excitation on resting [[ECG]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Oral [[digoxin]]  ([[ACC AHA guidelines classification scheme|Class 2b, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[AVRT]] without pre-excited [[AF]] that are not candidates or do not prefer catheter ablation<br>
❑  Because of low efficacy, in case of failure other [[antiarrhythmic]] agents, are recommended <br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Oral [[digoxin]] ([[ACC AHA guidelines classification scheme|Class 3,Harm, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Harmful in [[AVRT]] or [[AF]] and preexcitation on resting [[ECG]] due to decreased refractory period of [[accessory pathway]] and increased risk of [[VF]]<br>
|}


===Symptomatic Patients===
* Patients who have poorly tolerated symptoms or [[atrial fibrillation]] with rapid conduction should be treated with [[catheter ablation]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]).<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>


* Patients who have well tolerated symptoms can be treated with any of the following:
** [[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]), or
** [[Antiarrhythmic agents|Class I C antiarrhythmic agents]] such as: [[flecainide]], [[propafenone]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence C]]), or
** [[Sotalol]], [[amiodarone]] or [[beta blockers]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence C]])<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>


* [[AV node|AV nodal]] blocking agents such as [[digoxin]], [[verapamil]] and [[diltiazem]] should not be administered to patients with WPW syndrome and [[atrial fibrillation]] ([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]]).<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>


====Contraindicated medications====
==Recommendations for the management of [[patients]] with asymptomatic [[pre-excitation]]==
{{MedCondContrAbs|MedCond = WPW SYNDROME|Eletriptan|Diltiazem|Frovatriptan|Sumatriptan|Zolmitriptan}}
{| style="cellpadding=0; cellspacing= 0; width: 1200px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Performance of an [[electrophysiologic study]], with the use of [[isoprenaline]], is recommended to risk stratify individuals with asymptomatic pre-excitation who have high-risk [[occupations]]/[[hobbies]], or are competitive [[athletics]]<br>
❑[[Catheter ablation]] is recommended in asymptomatic [[patients]]  who are high risk in [[electrophysiology]] testing with the use of [[isoprenaline]], such as the shortest pre-excited [[RR interval]] during [[atrial fibrillation]]≤ 250 ms, [[accessory pathway]] [[effective refractory period]] ≤250 ms, multiple [[accessory pathway]]s, and an inducible [[accessory pathway]]-mediated [[tachycardia]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Catheter ablation]] is recommended in high-risk [[patients]] with asymptomatic pre-excitation after discussing the risks, especially of [[heart block]] associated with [[ablation]] of anteroseptal or mis-septal [[accessory pathway]], and benefits of the [[procedure]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''([[ESC guidelines classification scheme|Class 2a, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑  [[Patient]] should be clinically followed in the presence of asymptomatic pre-excitation and a low-risk [[accessory pathway]] at invasive [[risk stratification]]<br>
❑[[Catheter ablation]] should be considered in [[patients]] with asymptomatic pre-excitation and [[left ventricular dysfunction]] due to [[electrical dyssynchrony]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ESC guidelines classification scheme|Class 2b, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Catheter ablation]] may be considered in a [[patient]] with [[asymptomatic pre-excitation]], and a low-risk [[accessory pathway]] at invasive or non-invasive [[risk stratification]] <br>
❑ [[Catheter ablation]] may be considered in [[patients]] with low-risk asymptomatic pre-excitation in experienced centres according to [[patient]] preferences
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table 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>
|-
|}


==References==
==References==

Latest revision as of 13:19, 18 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]; Rim Halaby, M.D. [4]

Overview

Wolff-Parkinson-White syndrome patients who are hemodynamically unstable, as reflected by the presence of hypotension, cold extremities, mottling or peripheral cyanosis, or those who present with ischemic chest pain or decompensated heart failure should urgently undergo direct current cardioversion. The medical therapy of hemodynamically stable patients with WPW syndrome depends on the type of the tachycardia. When the ECG findings suggest orthodromic AVRT, the patient should be managed similarly to patients with supreventricular tachycardia followed by the sequential administration of adenosine, verapamil and procainamide in case of failure to improve. Among patients with antidromic AVRT, AV nodal blocking agents should be avoided and patients should be treated with either procainamide, ibutilide or flecainide. The long term treatment of patients with WPW syndrome depends on the presence or absence of symptoms and their severity. Patients who have poorly tolerated symptomatic WPW syndrome should undergo [[catheter ablation.

Acute Treatment

Atrioventricular Reentrant Tachycardia (AVRT)

  • AVRT is one of the type of tachycardia that can occur in patients with WPW pattern.
  • AVRT can be either orthodromic or antidromic and the treatment of them is different.

Hemodynamically Unstable Patients

  • WPW syndrome patients with AVRT who are hemodynamically unstable,should urgently undergo direct current cardioversion
  • The signs of instability of hemodynamic include the following:
  • hypotension,
  • cold extremities
  • mottling
  • peripheral cyanosis
  • chest pain
  • decompensated heart failure
    • The shocks should be delivered as follows:
    • Narrow regular rhythm: synchronized electrical cardioversion, 50-100 Joules
    • Narrow irregular rhythm: synchronized electrical cardioversion, 120-200 Joules biphasic or 200 Joules monophasic
    • Wide regular rhythm: synchronized electrical cardioversion, 100 Joules
    • Wide irregular rhythm: unsynchronized electrical cardioversion, 200-360 Joules monophasic, or 100-200 Joules biphasic[1]

Orthodromic AVRT in Hemodynamically Stable Patients

The sequence of therapeutic decisions is summarized below.[2]

Recommendations for acute treatment of orthodromic AVRT
Vagal maneuver (Class I, Level of Evidence B):

Carotid sinus massage for 5-10 seconds in the absence of bruit
Valsalva maneuver for 10-30 seconds by bearing down against closed glottis, a more successful technique
❑ Applying ice-cold wet towel to the face

Adenosin(Class I, Level of Evidence B) :

❑ Effective in conversion of AVRT in 90-95% patients
❑ Episode of AVRT may be induced again by PAC or PVC after termination of tachyarrhythmia by adenosin
AF may be induced by adenosin, rapidly passing through accessory pathway Contraindications: asthma, second degree AV block or third degree AV block unless a pacemaker is present

Synchronized cardioversion : (Class I, Level of Evidence B)
❑ Highly effective in termination of AVRT

❑ In unstable hemodynamic or stable hemodynamic and ineffectiveness of vagal maneuver or adenosine is recommended
❑ Avoidance of complications associated antiarrhythmic drugs
❑ In the presence of PVC or PAC just after cardioversion, antiarrhythmic drugs is recommended for prevention of restarting AVRT
❑ In the presence of hemodynamically unstable and pre excited AF, synchronized cardioversion is recommended

Ibutilide or intravenous procainamide:(Class I, Level of Evidence C)

❑ effective in hemodynamic stable and preexcited AF by slowing conduction over the accessory pathway
Contraindications: Compromised left ventricular function

Intravenous diltiazem,verapamil ,beta blockers : (Class 2a, Level of Evidence B-C)

❑ Effective for acute treatment of orthodromic AVRT without pre-excitation on resting ECG during sinus rhythm(LOR=B)
❑ Intravenous diltiazem or verapamil effectively terminate 90% to 95% of AVRT without pre-excitation on their resting sinus-rhythm ECG
❑ Hypotension may occur in 3% patients receiving Intravenous diltiazem or verapamil
❑ Intravenous beta blocker are effective for terminating AVRT with low risk of associated complications(LOR=C)

Intravenous betablockers,diltiazem,verapamil (Class 2b, Level of Evidence B):

❑ Acute termination of orthodromic AVRT with pre-excitation on resting ECG without response to other treatment
❑ The complication is enhancing conduction over the accessory pathway if the AVRT converts to AF during the administration of the medication

Intravenous digoxin,intravenous amiodarone,intravenous or oral beta blockers,diltiazem,verapamil : (Class 3, Harm, Level of Evidence B)

❑ Harmful in acute termination of peexcitated AF due to increased risk of ventricular fibrillation by these mechanisms:
❑ Increased conduction over the accessory pathway and slowing or blocking conduction over AV node
❑ Deceased refractory period of accessory pathway by digoxin
❑ Increased cathecolamin due to drug induced hypotension such as amiodarone, beta blocker, verapamil, diltiazem

Antidromic AVRT in Hemodynamically Stable Patients

Treatment of Antidromic AVRT in Hemodynamically Stable Patients
Medication Dosage Notes
Procainamide 100 mg infusion diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes ❑ 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

Ibutilide 1 mg IV infusion over 10 minutes ❑ Repeat the dosage if the tachycardia continues

Contraindications: hypersensitivity to ibutilide or any component of the formulation, QTc >440 msec

Atrial Fibrillation

Hemodynamically Unstable Patients

In hemodynamically unstable patients, urgent direct current cardioversion should be performed.[1]

Long Term Treatment

Management of patients with AVRT includes the following:[2]

Recommendations for longterm treatment of orthodromic AVRT
Catheter ablation (Class I, Level of Evidence B):

❑ Successful rate of ablation for AF+ AVRT is 93-95%
❑ In young patients, the risk of recurrent AF after ablation of the accessory pathway is low
❑ Recurrence of AF in older patients after ablation may be related to other causes
❑ Successful rate of ablation for mahain accessory pathway is 70-100%

Oral beta blockers, diltiazem, verapamil (Class I, Level of Evidence C):

❑ Effective in patients without preexcitation in resting ECG
❑ Prevention of AVRT recurrence in 50% patients

Oral flecainide or propafenone (Class 2a, Level of Evidence B):

❑ For patients with AVRT and/or pre-excited AF that are not candidates or do not prefer catheter ablation
❑ Mechanism of action is slowing or blocking conduction over the accessory pathway
❑ Contraindications are ischemic or structural heart disease due to increased risk of VT

Oral dofetilide or sotalol (Class 2b, Level of Evidence C):

❑ For patients with AVRT and/or pre-excited AF that are not candidated or do not prefer catheter ablation
❑ Be useful in patients with structural heart disease or coronary artery disease
❑ Side effect is QT prolongation and torsades de poites

Oral amiodarone (Class 2b, Level of Evidence C ):

❑ For patients with AVRT and/or pre-excited AF that are not candidated or do not prefer catheter ablation
❑ For patients that using betablocker, diltiazem or verapamil and flecainide are contraindicated or ineffective

Oral beta blockers, diltiazem, verapamil (Class 2b, Level of Evidence C):

❑For patients with AVRT and/or pre-excited AF that are not candidates or do not prefer catheter ablation
❑ Due to the risk of developing rapid AF in AVRT, these drugs should be used with causion
❑ Only one RCT supported the use of verapamil for the prevention of orthodromic AVRT in patients with pre-excitation on resting ECG

Oral digoxin (Class 2b, Level of Evidence C):

❑ In AVRT without pre-excited AF that are not candidates or do not prefer catheter ablation
❑ Because of low efficacy, in case of failure other antiarrhythmic agents, are recommended

Oral digoxin (Class 3,Harm, Level of Evidence C):

❑ Harmful in AVRT or AF and preexcitation on resting ECG due to decreased refractory period of accessory pathway and increased risk of VF



Recommendations for the management of patients with asymptomatic pre-excitation

(Class I, Level of Evidence B):

❑Performance of an electrophysiologic study, with the use of isoprenaline, is recommended to risk stratify individuals with asymptomatic pre-excitation who have high-risk occupations/hobbies, or are competitive athletics
Catheter ablation is recommended in asymptomatic patients who are high risk in electrophysiology testing with the use of isoprenaline, such as the shortest pre-excited RR interval during atrial fibrillation≤ 250 ms, accessory pathway effective refractory period ≤250 ms, multiple accessory pathways, and an inducible accessory pathway-mediated tachycardia

(Class I, Level of Evidence C):

Catheter ablation is recommended in high-risk patients with asymptomatic pre-excitation after discussing the risks, especially of heart block associated with ablation of anteroseptal or mis-septal accessory pathway, and benefits of the procedure

(Class 2a, Level of Evidence C):

Patient should be clinically followed in the presence of asymptomatic pre-excitation and a low-risk accessory pathway at invasive risk stratification
Catheter ablation should be considered in patients with asymptomatic pre-excitation and left ventricular dysfunction due to electrical dyssynchrony

(Class 2b, Level of Evidence C):

Catheter ablation may be considered in a patient with asymptomatic pre-excitation, and a low-risk accessory pathway at invasive or non-invasive risk stratification
Catheter ablation may be considered in patients with low-risk asymptomatic pre-excitation in experienced centres according to patient preferences

The above table adopted from 2019 ESC Guideline[3]

References

  1. 1.0 1.1 "Part 8: Adult Advanced Cardiovascular Life Support". Retrieved 3 April 2014.
  2. 2.0 2.1 2.2 Page, Richard L.; Joglar, José A.; Caldwell, Mary A.; Calkins, Hugh; Conti, Jamie B.; Deal, Barbara J.; Estes III, N.A. Mark; Field, Michael E.; Goldberger, Zachary D.; Hammill, Stephen C.; Indik, Julia H.; Lindsay, Bruce D.; Olshansky, Brian; Russo, Andrea M.; Shen, Win-Kuang; Tracy, Cynthia M.; Al-Khatib, Sana M. (2016). "2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia". Heart Rhythm. 13 (4): e136–e221. doi:10.1016/j.hrthm.2015.09.019. ISSN 1547-5271.
  3. 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.

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