Wolff-Parkinson-White syndrome

Last reviewed: May 2019

Last updated: June 2018

Summary

Myocardial fibres extending from the atrium to the ipsilateral ventricle across the mitral or tricuspid annulus (accessory pathway) pre-excite the ventricle.

WPW syndrome is restricted to symptomatic patients with a typical ECG abnormality; WPW pattern signifies an asymptomatic patient with typical ECG abnormalities.

Patients often present with atrioventricular re-entrant tachycardia, less commonly atrial fibrillation, and, rarely, sudden cardiac death.

Asymptomatic patients can either be monitored or screened to determine whether they have a 'high-risk' accessory pathway, in which case catheter ablation is typically performed. Screening to determine whether a patient has a high-risk accessory pathway is recommended for patients who have high-risk occupations, such as school bus drivers or pilots, and also for competitive athletes.

Symptomatic patients usually undergo catheter ablation as first-line therapy. Pharmacological therapy can be considered for patients in whom catheter ablation fails and also for patients who prefer a non-invasive approach.

Catheter ablation is highly effective with low risk and can be used either as initial therapy or for patients experiencing side effects or arrhythmia recurrences despite medical treatment.

Definition

Occurs when one or more strands of myocardial fibres capable of conducting electrical impulses (known as accessory pathways [APs] or bypass tracts) connect the atrium to the ipsilateral ventricle across the mitral or tricuspid annulus. [1] Conduction from the atrium reaches the adjacent ventricle earlier via the AP, and a part of the ventricle is pre-excited. The term 'Wolff-Parkinson-White (WPW) syndrome' is restricted to symptomatic patients with a typical ECG abnormality, whereas the term 'WPW pattern' signifies an asymptomatic patient with typical ECG abnormalities. [2]

History and exam

Key diagnostic factors

presence of risk factors
atrioventricular re-entrant tachycardia (AVRT)

Full details

Other diagnostic factors

palpitations
dizziness
shortness of breath
chest pain
atrial fibrillation
atrial flutter
congenital cardiac abnormalities
sudden cardiac death
syncope and presyncope
tachycardia in pregnancy

Full details

Risk factors

Ebstein's anomaly
hypertrophic cardiomyopathy
mitral valve prolapse
atrial septal defect
ventricular septal defect
transposition of great vessels
coarctation of aorta
dextrocardia
coronary sinus diverticula
right and left atrial aneurysms
cardiac rhabdomyomas
Marfan's syndrome
Friedreich's ataxia
family history

Full details

Diagnostic investigations

1st investigations to order

12-lead ECG

Full details

Investigations to consider

echocardiogram
treadmill exercise test
electrophysiology study

Full details

Treatment algorithm

INITIAL

unstable: BP <90/60 mmHg, signs of systemic hypoperfusion or unstable atrial fibrillation

ACUTE

stable: narrow complex (orthodromic atrioventricular reciprocating) tachycardia

stable: wide complex (antidromic atrioventricular reciprocating) tachycardia

stable: pre-excited tachycardia due to atrial fibrillation or atrial flutter

stable: pre-excited tachycardia due to atrial tachycardia

ONGOING

following acute treatment: asymptomatic

following acute treatment: symptomatic

Contributors

Authors VIEW ALL 

Hugh Calkins, MD

Professor of Medicine

Director of Electrophysiology

Johns Hopkins University School of Medicine

Baltimore

Disclosures

HC declares that he is a consultant for Medtronic and Biosense Webster; receives research support from Boston Scientific; is a contributor to Up to Date on atrial fibrillation, arrhythmogenic right ventricular dysplasia, and sarcoidosis; has reviewed and testified in medical malpractice cases; and has authored a chapter in the European Society of Cardiology textbook on Wolff-Parkinson-White syndrome.

Acknowledgements

Professor Hugh Calkins would like to gratefully acknowledge Dr David Frankel, Dr Mithilesh K. Das, and Dr Douglas P. Zipes, previous contributors to this topic. DF, MKD, and DPZ declare that they have no competing interests.

Peer reviewers VIEW ALL 

Joseph E. Marine, MD

Associate Professor of Medicine

Director of Electrophysiology

Johns Hopkins University School of Medicine

Baltimore

Disclosures

JEM declares that he has no competing interests.

Suneet Mittal, MD

Director

Electrophysiology Laboratory

The St. Luke's-Roosevelt Hospital Center

New York

Disclosures

SM declares that he has no competing interests.

Andrew Turley, MB ChB

Cardiology Specialist Registrar

The James Cook University Hospital

Middlesbrough

Disclosures

AT declares that he has no competing interests.

Steve Hsu, MD

Associate Professor

Department of Medicine

Division of Cardiology

University of Florida College of Medicine

Jacksonville

Disclosures

SH declares that he has no competing interests.

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Wolff-Parkinson-White syndrome

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

unstable: BP <90/60 mmHg, signs of systemic hypoperfusion or unstable atrial fibrillation

stable: narrow complex (orthodromic atrioventricular reciprocating) tachycardia

stable: wide complex (antidromic atrioventricular reciprocating) tachycardia

stable: pre-excited tachycardia due to atrial fibrillation or atrial flutter

stable: pre-excited tachycardia due to atrial tachycardia

following acute treatment: asymptomatic

following acute treatment: symptomatic

Contributors

Authors VIEW ALL 

Hugh Calkins, MD

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Joseph E. Marine, MD

Disclosures

Suneet Mittal, MD

Disclosures

Andrew Turley, MB ChB

Disclosures

Steve Hsu, MD

Disclosures

Differentials

Guidelines

Patient leaflets

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