Wolff-Parkinson-White syndrome EKG: Difference between revisions

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Latest revision as of 11:33, 19 August 2022

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

Overview

Wolff-Parkinson-White (WPW) pattern is characterized by ECG findings such as a short PR interval and a delta wave and wide QRS complex.WPW syndrome is the occurrence of tachycardia with or without associated symptoms in a subject with existing WPW pattern. WPW syndrome can present as an orthodromic or antidromic AVRT during which the delta wave no longer appears. Atrial fibrillation in a patient with WPW should be suspected when there is ECG findings of an irregularly irregular rhythm and absent P waves suggestive of atrial fibrillation in the context of a heart rate higher than 240 beats per minute.

WPW Pattern

WPW pattern is characterized by the following typical EKG findings:
- Short PR interval: The PR interval is short because the ventricles begins to contract earlier than usual because of the electrical signal travels through the accessory pathway faster than the AV node.
- Wide QRS
- delta wave
- QRS alternans
- ST segment depression.
Preexcitation and presence of delta waves typical of WPW syndrome or WPW pattern may either mimic myocardial infarction or may mask it.^[1]
- Abolishment of delta waves may be necessary for the diagnosis of myocardial infarction on EKG.^[2]
- Left posterolateral or lateral accessory pathways may mask inferior or anteroseptal myocardial infarction .^[3]
- Posteroseptal accessory pathways may mask an anterior MI.^[3]
- Right anteroseptal and anterolateral accessory pathways may mask inferior or anterolateral MI.^[3]

Determining the location of the accessory pathway

V1

_

+

Positive inferior leads

0

1,2

3

1,2

0

V3

Left lateral

Left posterolateral

V1/1 ratio

_

+

Right posterior

Right paraseptal

<1

≥1

_

+

Lead 2, Notched QS

Left posterolateral

Right lateral

Nodo-Hisian

Yes

NO

_

+

Deep coronary sinus

Left paraseptal

Nodo-Hisian

Right atrium

The above algorithm adopted from 2019 ESC Guideline^[4]

WPW Syndrome

WPW syndrome is the occurrence of tachycardia with or without associated symptoms in a subject with existing WPW pattern.^[5]
Several types of arrhythmia can occur in WPW syndrome such as AV reentrant tachycardia (AVRT), atrial fibrillation,or atrial flutter

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

Orthodromic AVRT

In orthodromic AVRT, the anterograde conduction (from the atrium to the ventricle) passes through theAV node and the retrograde conduction (from the ventricle to the atrium) passes through the accessory pathway.
Orthodromic AVRT occurs in approximately 90 to 95% of WPW.

The EKG findings include the following:

Regular rhythm
Narrow QRS complexes
Retrograde P wave following the QRS complex
Long RP, short PR tachycardia

Antidromic AVRT

The anterograde conduction (from the atrium to the ventricle) passes through the accessory pathway and the retrograde conduction (from the ventricle to the atrium) passes through the AV node.
It apprears in less than 10% of WPW.
The EKG findings may include the following:
Regular rhythm
Wide QRS complexes tachycardia

Atrial Fibrillation in WPW

Atrial fibrillation in WPW syndrome is life-threatening because it might lead to ventricular tachycardia.
The suggestive findings of [[antidromic AVRT] and rapid atrial fibrillation on the ECG may include the following:
Irregularly irregular rhythm
Absent of P wave
Wide WRS
Ventricular rate >240 beats per minute^[7]

Shown below is an ECG depicting an irregularly irregular rhythm with wide QRS and absent P waves suggestive of atrial fibrillation in WPW syndrome.

Examples

Shown below is an EKG of Wolff-Parkinson-White syndrome demonstrating slurred upstroke of the QRS complex (>110 milli sec), resulting in a delta-wave (arrow). The EKG also shows a short PR interval.

Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page

Shown below is an EKG showing a slurred upstroke QRS complex which is best appreciated in the precordial leads and a PR interval of less than 120 ms (short PR interval) suggesting WPW syndrome.

Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page

Shown below is an EKG demonstrating a delta wave in leads V₂, I, aVL, with wide QRS complexes and left axis deviation suggesting WPW syndrome.

Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page

Shown below is an EKG showing a short PR interval of less than 120 ms, delta waves in leads I, aVF, aVL and chest leads with wide QRS complexes indicating WPW syndrome.

Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page

For more EKG examples of Wolff-Parkinson-White syndrome click Wolff-Parkinson-White syndrome EKG examples here.

References

↑ Smolders L, Majidi M, Krucoff MW, Crijns HJ, Wellens HJ, Gorgels AP (2008). "Preexcitation and myocardial infarction: conditions with confusing electrocardiographic manifestations". J Electrocardiol. 41 (6): 679–82. doi:10.1016/j.jelectrocard.2008.05.005. PMID 18602643.
↑ Liu R, Chang Q (2013). "The diagnosis of myocardial infarction in the Wolff-Parkinson-White syndrome". Int J Cardiol. 167 (3): 1083–4. doi:10.1016/j.ijcard.2012.10.055. PMID 23157811.
↑ ^3.0 ^3.1 ^3.2 Preminger MW, Callans DJ, Gottlieb CD, Marchlinski FE (1994). "Radiofrequency catheter ablation used to unmask infarction Q waves in Wolff-Parkinson-White syndrome". Am Heart J. 128 (5): 1040–2. PMID 7942468.
↑ 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.
↑ "Wolff-Parkinson-White Syndrome and Accessory Pathways". Retrieved 1 April 2014.
↑ "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.
↑ Klein, George J.; Bashore, Thomas M.; Sellers, T. D.; Pritchett, Edward L. C.; Smith, William M.; Gallagher, John J. (1979). "Ventricular Fibrillation in the Wolff-Parkinson-White Syndrome". New England Journal of Medicine. 301 (20): 1080–1085. doi:10.1056/NEJM197911153012003. ISSN 0028-4793.

Template:WH Template:WS

[pmid18602643-1] Smolders L, Majidi M, Krucoff MW, Crijns HJ, Wellens HJ, Gorgels AP (2008). "Preexcitation and myocardial infarction: conditions with confusing electrocardiographic manifestations". J Electrocardiol. 41 (6): 679–82. doi:10.1016/j.jelectrocard.2008.05.005. PMID 18602643.

[pmid23157811-2] Liu R, Chang Q (2013). "The diagnosis of myocardial infarction in the Wolff-Parkinson-White syndrome". Int J Cardiol. 167 (3): 1083–4. doi:10.1016/j.ijcard.2012.10.055. PMID 23157811.

[pmid7942468-3] 3.0 ^3.1 ^3.2 Preminger MW, Callans DJ, Gottlieb CD, Marchlinski FE (1994). "Radiofrequency catheter ablation used to unmask infarction Q waves in Wolff-Parkinson-White syndrome". Am Heart J. 128 (5): 1040–2. PMID 7942468.

[pmid31504425-4] Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A (February 2020). "2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC)". Eur Heart J. 41 (5): 655–720. doi:10.1093/eurheartj/ehz467. PMID 31504425.

[5] "Wolff-Parkinson-White Syndrome and Accessory Pathways". Retrieved 1 April 2014.

[circ.ahajournals.org-6] "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.

[KleinBashore1979-7] Klein, George J.; Bashore, Thomas M.; Sellers, T. D.; Pritchett, Edward L. C.; Smith, William M.; Gallagher, John J. (1979). "Ventricular Fibrillation in the Wolff-Parkinson-White Syndrome". New England Journal of Medicine. 301 (20): 1080–1085. doi:10.1056/NEJM197911153012003. ISSN 0028-4793.

[1]

[2]

[3]

[4]

[5]

[6]

[7]

@@ Line 2: / Line 2: @@
 {{Wolff-Parkinson-White syndrome}}
-{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
+{{CMG}}; '''Associate Editor-In-Chief:''' {{Sara.Zand}} {{CZ}}
 ==Overview==
-Wolff-Parkinson-White (WPW) pattern is characterized by the presence of characteristic [[ECG]] findings, such as a short [[PR interval]] and a [[delta wave]].   WPW syndrome is the occurrence of [[tachycardia]] with or without associated symptoms in a subject with existing [[WPW]] pattern.<ref>{{Cite web  | last =  | first =  | title = Wolff-Parkinson-White Syndrome and Accessory Pathways | url = http://circ.ahajournals.org/content/122/15/e480.full | publisher =  | date =  | accessdate = 1 April 2014 }}</ref>  Several types of arrhythmia can occur in WPW syndrome such as [[AV reentrant tachycardia]] (AVRT), [[atrial fibrillation]],or [[atrial flutter]], the most common of which is [[AVRT]].<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher =  | date =  | accessdate = 15 August 2013 }}</ref> WPW syndrome can present as an orthodromic or antidromic [[AVRT]] during which the [[delta wave]] no longer appears.  [[Atrial fibrillation]] in a patient with [[WPW]] should be suspected when there is [[ECG]] findings of an irregularly irregular rhythm and absent [[P wave]]s suggestive of [[atrial fibrillation]] in the context of a [[heart rate]] higher than 220 beats per minute.
+[[Wolff-Parkinson-White]] ([[WPW]]) pattern is characterized by  [[ECG]] findings such as a short [[PR interval]] and a [[delta wave]] and wide [[QRS]] complex.[[ WPW syndrome]] is the occurrence of [[tachycardia]] with or without associated symptoms in a subject with existing [[WPW]] pattern. [[WPW syndrome]] can present as an orthodromic or antidromic [[AVRT]] during which the [[delta wave]] no longer appears.  [[Atrial fibrillation]] in a patient with [[WPW]] should be suspected when there is [[ECG]] findings of an irregularly irregular [[rhythm]] and absent [[P wave]]s suggestive of [[atrial fibrillation]] in the context of a [[heart rate]] higher than 240 beats per minute.
-==WPW Pattern==
+==[[WPW]] Pattern==
-*WPW pattern is characterized by the following typical [[ECG]] findings:
+*[[WPW]] pattern is characterized by the following typical [[EKG]] findings:
-** Short [[PR interval]]: The [[PR interval]] is short because the [[ventricles]] begins to contract earlier than usual because the electrical signal travels through the accessory pathway faster than the [[AV node]].
+** Short [[PR interval]]: The [[PR interval]] is short because the [[ventricles]] begins to contract earlier than usual because of the electrical signal travels through the [[accessory pathway]] faster than the [[AV node]].
-** [[Wide QRS]]
+**[[Wide QRS]]
-** Presence of a [[delta wave]]
+**[[delta wave]]
-* Other findings that can be present in a subject with an accessory pathway include [[QRS alternans]] and [[ST segment depression]].
+**[[QRS alternans]]
+**[[ST segment depression]].
+*Preexcitation and presence of [[delta wave]]s typical of [[WPW syndrome]] or [[WPW pattern]] may either mimic [[myocardial infarction]] or may mask it.<ref name="pmid18602643">{{cite journal| author=Smolders L, Majidi M, Krucoff MW, Crijns HJ, Wellens HJ, Gorgels AP| title=Preexcitation and myocardial infarction: conditions with confusing electrocardiographic manifestations. | journal=J Electrocardiol | year= 2008 | volume= 41 | issue= 6 | pages= 679-82 | pmid=18602643 | doi=10.1016/j.jelectrocard.2008.05.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18602643  }} </ref><br>
+**Abolishment of [[delta waves]] may be necessary for the diagnosis of [[myocardial infarction]] on [[EKG]].<ref name="pmid23157811">{{cite journal| author=Liu R, Chang Q| title=The diagnosis of myocardial infarction in the Wolff-Parkinson-White syndrome. | journal=Int J Cardiol | year= 2013 | volume= 167 | issue= 3 | pages= 1083-4 | pmid=23157811 | doi=10.1016/j.ijcard.2012.10.055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23157811  }} </ref><br>
+**Left posterolateral or lateral [[accessory pathways]] may mask inferior or anteroseptal [[ myocardial infarction ]].<ref name="pmid7942468">{{cite journal| author=Preminger MW, Callans DJ, Gottlieb CD, Marchlinski FE| title=Radiofrequency catheter ablation used to unmask infarction Q waves in Wolff-Parkinson-White syndrome. | journal=Am Heart J | year= 1994 | volume= 128 | issue= 5 | pages= 1040-2 | pmid=7942468 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7942468  }} </ref><br>
+**Posteroseptal accessory pathways may mask an [[anterior MI]].<ref name="pmid7942468">{{cite journal| author=Preminger MW, Callans DJ, Gottlieb CD, Marchlinski FE| title=Radiofrequency catheter ablation used to unmask infarction Q waves in Wolff-Parkinson-White syndrome. | journal=Am Heart J | year= 1994 | volume= 128 | issue= 5 | pages= 1040-2 | pmid=7942468 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7942468  }} </ref><br>
+**Right anteroseptal and anterolateral [[accessory pathways]] may mask inferior or [[anterolateral MI]].<ref name="pmid7942468">{{cite journal| author=Preminger MW, Callans DJ, Gottlieb CD, Marchlinski FE| title=Radiofrequency catheter ablation used to unmask infarction Q waves in Wolff-Parkinson-White syndrome. | journal=Am Heart J | year= 1994 | volume= 128 | issue= 5 | pages= 1040-2 | pmid=7942468 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7942468  }} </ref>
 == Determining the location of the accessory pathway==
-{| class= "wikitable"
+{{Family tree/start}}
-|colspan = "6" align="left"| '''Check lead V1'''
+{{Family tree | | | | | | | | | | | | | | | | B01 | | | |B01= V1}}
-|-
+{{Family tree | | | | | | | | | | | | | |,|-|-|^|-|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | | | |}}
-|colspan ="3"| Negative delta wave in V1 = right ventricle
+{{Family tree | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | |C02  |C01=_ | C02=+|}}
-||
+{{Family tree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
-|colspan ="2"| Positive delta wave im V1= left ventricle
+{{Family tree | | | | | | | | | | | | |   D1| | | | | | | | | | | | | | | | |  D1 | | | | | | | | | | | | | | | D1= Positive inferior leads| | | |}}
-|-
+{{Family tree | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | |}}
-| Negative delta wave and QRS in II, III, AVF || Left axis || Inferior axis|| ||Negative delta wave and QRS in II, III, AVF || Isoelectric or negative delta I, AVL, V5, V6
+{{Family tree | | | | | | | | | | |D2 | |D3 | |D4 | | | | | | | |K2 | |K3 | |K4 | | | | | | | | | | |K4=0 |K3=1,2 |D4=3 | D3=1,2|D2=0 | K2=3|}}
-|-
+{{Family tree | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | |}}
-| Posteroseptal || Right free wall || Anteroseptal ||||Posteroseptal || Lateral
+{{Family tree | | | | | | | | | | |F1 | |F1 | |F1 | | | | | | |L1 | | |L2 | |L3 | | | | | | | | | | | | | | | | |F1=V3 |L1=Left lateral |L2= Left posterolateral | L3= V1/1 ratio| | |}}
-|-
+{{Family tree | | | | | | | | |,|-|^|.| | | |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | | |}}
+{{Family tree | | | | | | | | G1| | G2| |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | |G2=+ |G1=_ |}}
+{{Family tree | | | | | | | | |!| | |!| | | |:| | | | |:| | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | |}}
+{{Family tree | | | | | | | |H1 | |H2 | |:| | | | |:| | | | | | | | | | | | | | |J1 | | J2| | | | | | | | | | | |J1= <1 |J2=≥1 | H2=Right paraseptal|H1=Right posterior| |}}
+{{Family tree | | | | | | | | | | | | |,|-|-|^|.| | | |:| | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | |}}
+{{Family tree | | | | | | | | | | | | H3| | |H4 | |:| | | | | | | | | | | | | | | M1| | |N1 | | | | | | | | | | | |M1=Lead 2, Notched QS | N1=Left posterolateral| H3=_|H4=+ |}}
+{{Family tree | | | | | | | | | | | | |!| | | |!| | | |:| | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | }}
+{{Family tree | | | | | | | | | | | |H5 | |H6 | | |:| | | | | | | | | | | | | Y1| | Y2| | | | | | | | | |Y2=NO |Y1= Yes |H6=[[Nodo-Hisian]] |H5=Right lateral |}}
+{{Family tree | | | | | | | | | | | | | | | | |,|-|-|-|^|.| | | | | | | | | | | |!| | | |!| | | | | | | | | | | | |}}
+{{Family tree | | | | | | | | | | | | | | | | |j1 | | |j2 | | | | | | | | | |Y3 | |Y4 | | | | | | | | | |Y4=Left paraseptal |Y3=Deep coronary sinus | j1=_| j2=+| }}
+{{Family tree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
+{{Family tree | | | | | | | | | | | | | | | | |J3 | | | J4| | | | | | | | | | | | | | | | | | | | | | | | | | |J3=[[Nodo-Hisian]] | |J4=[[Right atrium]] | |}}
+{{Family tree/end}}
+{|
+! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2019 ESC Guideline<ref name="pmid31504425">{{cite journal |vauthors=Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A |title=2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC) |journal=Eur Heart J |volume=41 |issue=5 |pages=655–720 |date=February 2020 |pmid=31504425 |doi=10.1093/eurheartj/ehz467 |url=}}</ref>
+|-
 |}
-==WPW Syndrome==
+==[[WPW Syndrome]]==
-WPW syndrome is the occurrence of [[tachycardia]] with or without associated symptoms in a subject with existing [[WPW]] pattern.<ref>{{Cite web  | last =  | first =  | title = Wolff-Parkinson-White Syndrome and Accessory Pathways | url = http://circ.ahajournals.org/content/122/15/e480.full | publisher =  | date =  | accessdate = 1 April 2014 }}</ref>  Several types of arrhythmia can occur in WPW syndrome such as [[AV reentrant tachycardia]] (AVRT), [[atrial fibrillation]],or [[atrial flutter]], the most common of which is [[AVRT]].<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher =  | date =  | accessdate = 15 August 2013 }}</ref>
+*[[WPW syndrome]] is the occurrence of [[tachycardia]] with or without associated symptoms in a subject with existing [[WPW]] pattern.<ref>{{Cite web  | last =  | first =  | title = Wolff-Parkinson-White Syndrome and Accessory Pathways | url = http://circ.ahajournals.org/content/122/15/e480.full | publisher =  | date =  | accessdate = 1 April 2014 }}</ref>
+*Several types of [[ arrhythmia]] can occur in [[WPW syndrome]] such as [[AV reentrant tachycardia]] (AVRT), [[atrial fibrillation]],or [[atrial flutter]]
+the most common type of [[tachyarrhythmia]] is [[AVRT]].<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher =  | date =  | accessdate = 15 August 2013 }}</ref>
-====Orthodromic AVRT====
+====[[Orthodromic AVRT]]====
-The anterograde conduction (from the atrium to the ventricle) passes through the AV node and the retrograde conduction (from the ventricle to the atrium) passes through the accessory pathway. It apprears in 90 to 95% of [[WPW]].<br>
+*In orthodromic AVRT, the anterograde conduction (from the [[atrium]] to the [[ventricle]]) passes through the[[ AV node]] and the retrograde conduction (from the [[ventricle]] to the [[atrium]]) passes through the [[accessory pathway]].
-The [[EKG]] findings include:
+* Orthodromic [[AVRT]] occurs in approximately 90 to 95% of [[WPW]].
-* Regular rhythm<br>
+The [[EKG]] findings include the following:
-* Narrow QRS complexes <br>
+* Regular [[rhythm]]<br>
-* [[P wave]] before [[QRS]]<br>
+* Narrow [[QRS complex]]es <br>
+* Retrograde [[P wave]] following the [[QRS]] complex <br>
+* Long RP, short PR tachycardia
 [[File:SVT.jpg|800px|center]]
 ====Antidromic AVRT====
-The anterograde conduction (from the atrium to the ventricle) passes through the accessory pathway and the retrograde conduction (from the ventricle to the atrium) passes through the AV node. It apprears in less than 10% of [[WPW]].<br>
+*The [[anterograde conduction]] (from the [[atrium]] to the [[ventricle]]) passes through the [[accessory pathway]] and the [[retrograde conduction]] (from the [[ventricle]] to the [[atrium]]) passes through the [[AV node]].
-The [[EKG]] findings include:
+* It apprears in less than 10% of [[WPW]].<br>
-* Regular rhythm<br>
+*The [[EKG]] findings may include the following:
-* [[Wide QRS complexes]] <br>
+* Regular [[rhythm]]<br>
-* [[P wave]] after [[QRS]] <br>
+* [[Wide QRS complexes]] [[tachycardia]] <br>
 [[File:Wide complex tachy.jpg|800px|center]]
-==Clinical Manifestations==
+==[[Atrial Fibrillation]] in [[WPW]]==
+*[[Atrial fibrillation]] in [[WPW]] syndrome is life-threatening because it might lead to [[ventricular tachycardia]].
+* The suggestive findings of [[antidromic AVRT] and rapid [[atrial fibrillation]] on  the [[ECG]] may include the following:
+* Irregularly irregular [[ rhythm]]
+* Absent of [[P wave]]
+* [[Wide WRS]]
+* [[Ventricular rate]] >240 beats per minute<ref name="KleinBashore1979">{{cite journal|last1=Klein|first1=George J.|last2=Bashore|first2=Thomas M.|last3=Sellers|first3=T. D.|last4=Pritchett|first4=Edward L. C.|last5=Smith|first5=William M.|last6=Gallagher|first6=John J.|title=Ventricular Fibrillation in the Wolff-Parkinson-White Syndrome|journal=New England Journal of Medicine|volume=301|issue=20|year=1979|pages=1080–1085|issn=0028-4793|doi=10.1056/NEJM197911153012003}}</ref>
-# The most common form of paroxysmal tachycardia in these patients is a circus movement tachycardia (CMT) incorporating the AP.
+Shown below is an [[ECG]] depicting an irregularly irregular rhythm with [[wide QRS]] and absent [[P waves]] suggestive of [[atrial fibrillation]] in [[WPW syndrome]].
-# The CMT utilizes the following structures: the AV node, the His-Purkinje system, the ventricular myocardium (from the terminal portion of the His system to the ventricular end of the AP), the AP itself, and the atrial myocardium itself from the atrial insertion of the AP to the AV node.
-# This circuit can conduct in both directions:
-#* Type I A CMT:
-#*:# This is the usual form of the CMT in patients with WPW.
-#*:# Is antegrade through the [[AV node]], VA conduction through the AP.
-#*:# The QRS complex during the tachycardia shows either normal intraventricular conduction or typical bundle branch block configuration.
-#*:# Symptoms: [[Palpitations]] (97%), [[dyspnea]] (57%), anginal pain (56%), [[perspiration]] (55%), [[fatigue]] (41%), [[anxiety]] (30%), [[dizziness]] (30%),[[polyuria]] (26%).
-#*:# This is also called orthodromic reentrant tachycardia.
-#*:# There is no delta wave.
-#*:# The rate is 140 to 250 bpm.
-#*:# It is faster than the rate of tachycardia due to reentry in the AV node.
-#*:# Often triggered by a PAC
-[[File:Orthodromic AVRT.png|200px|center]]<br>
-#* Type I B CMT:
-#*:# Anterograde down the accessory pathway, retrograde in the AVN-His pathway.
-#*:# The QRS is widened ([[wide QRS]])
-#*:# This form is rare.
-#*:# Also called antidromic reentrant tachycardia.
-[[File:Antidromic AVRT.png|200px|center]] <br>
-#* Type II CMT (intra-AV nodal):
-#*:# Anterograde pathway is an AV nodal slow pathway, the retrograde pathway is an AV nodal fast pathway.
-#*:# No evidence of ventricular pre-excitation during the tachycardia.
-#* Type III CMT (uses two accessory pathways):
-#*:# Conducts anterograde down one accessory pathway and retrograde up a second accessory pathway.
-#*:# These patients can also experience atrial tachycardias and ventricular tachycardias.
-==Atrial Fibrillation in WPW==
+[[File:Wpw with afib.PNG|center|300px]]
-Can cause life-threatening ventricular rates due to the exclusive AV conduction over the accessory pathway.
-#* Reduces cardiac output.
-#* May degenerate into VF, particularly in those with multiple bypass tracts.
-# The only marker identified for degeneration into VF in the literature was the occurrence of RR intervals equal to or less than 205 msec during the a fib
-# Seen in 78 of 256 of Wellen's patients with WPW. Reported incidence is 20 to 35% in other studies.
-# The degree of ventricular preexcitation observed in the EKG during NSR bears no relationship whatsoever to the risk of developing life-threatening ventricular rates during the a.fib.
-# The QRS complexes are wide and bizarre as a result of preexcitation.
-# The ventricular rate is 220 to 360 beats per minute due to the short effective refractory period of the accessory pathway.
-# It is often mistaken for VT.
-# If the atrial rate in atrial fibrillation is greater than 200 BPM then suspect this. The rhythm will also be grossly irregular if it is due to atrial fibrillation. Such a rapid rate would be unusual if it were due to conduction by way of the normal AV conduction system.
 ==Examples==
-Shown below is an EKG of [[Wolff-Parkinson-White syndrome]] demonstrating slurred upstroke of the [[QRS complex]] (>110 milli sec), resulting in a [[delta-wave]] (arrow). The EKG also shows a [[short PR interval]].[[File:Rhythm_WPW.png|center|800px]]
+Shown below is an [[EKG]] of [[Wolff-Parkinson-White syndrome]] demonstrating slurred upstroke of the [[QRS complex]] (>110 milli sec), resulting in a [[delta-wave]] (arrow). The EKG also shows a [[short PR interval]].[[File:Rhythm_WPW.png|center|800px]]
 Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
 ----
-Shown below is an EKG showing a slurred upstroke [[QRS]] complex which is best appreciated in the [[precordial leads]] and a [[PR interval]] of less than 120 ms ([[short PR interval]]) suggesting WPW syndrome.
+Shown below is an [[EKG]] showing a slurred upstroke [[QRS]] complex which is best appreciated in the [[precordial leads]] and a [[PR interval]] of less than 120 ms ([[short PR interval]]) suggesting [[WPW syndrome]].
 [[Image:Wolf_Parkinson_White_syndrome.png|center|800px]]
 Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
@@ Line 100: / Line 98: @@
 ----
-Shown below is an EKG demonstrating a [[delta wave]] in leads [[Precordial leads|V<sub>2</sub>]], I, aVL, with [[wide QRS complexes]] and [[left axis deviation]] suggesting WPW syndrome.
+Shown below is an [[EKG]] demonstrating a [[delta wave]] in leads [[Precordial leads|V<sub>2</sub>]], I, aVL, with [[wide QRS complexes]] and [[left axis deviation]] suggesting [[WPW syndrome]].
 [[Image:WPW_syndrome_1.jpg|center|800px]]
 Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
@@ Line 106: / Line 104: @@
 ----
-Shown below is an EKG showing a [[short PR interval]] of less than 120 ms, delta waves in leads [[Limb lead|I]], [[Augmented limb lead|aVF]], [[Augmented limb lead|aVL]] and chest leads with [[wide QRS]] complexes indicating [[WPW syndrome]].
+Shown below is an [[EKG]] showing a [[short PR interval]] of less than 120 ms, delta waves in leads [[Limb lead|I]], [[Augmented limb lead|aVF]], [[Augmented limb lead|aVL]] and [[chest]] leads with [[wide QRS]] complexes indicating [[WPW syndrome]].
 [[Image:WPW_syndrome_2.jpg|center|800px]]
 Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
@@ Line 112: / Line 110: @@
 ----
-;For more EKG examples of Wolff-Parkinson-White syndrome click [[Wolff-Parkinson-White syndrome EKG examples|here]].
+; For more [[EKG]] examples of [[Wolff-Parkinson-White syndrome]] click [[Wolff-Parkinson-White syndrome]] [[EKG]] examples here.
 ==References==

Wolff-Parkinson-White syndrome EKG: Difference between revisions

Latest revision as of 11:33, 19 August 2022

Overview

WPW Pattern

Determining the location of the accessory pathway

WPW Syndrome

Orthodromic AVRT

Antidromic AVRT

Atrial Fibrillation in WPW

Examples

References

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