Wolff-Parkinson-White syndrome

Last reviewed: April 2018

Last updated: November 2017

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 AV re-entrant tachycardia, less commonly atrial fibrillation, and, rarely, sudden cardiac death.

Asymptomatic patients, except for those with specialised jobs (e.g., airline pilot, school bus driver), should not be treated but can be monitored for symptoms.

Minimally symptomatic patients may be treated with catheter ablation or medical therapy, either on a routine basis or as needed during symptomatic episodes.

Symptomatic patients usually undergo catheter ablation as first-line therapy.

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
SOB
chest pain
atrial fibrillation
atrial flutter
congenital cardiac abnormalities
sudden cardiac death (SCD)
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
pharmacological testing with procainamide or ajmaline
electrophysiology study

Full details

Treatment algorithm

INITIAL

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

ACUTE

stable: narrow complex (orthodromic AV reciprocating) tachycardia

stable: wide complex (antidromic AV 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: minimally symptomatic

following acute treatment: symptomatic

Contributors

Authors VIEW ALL 

David Frankel, MD

Associate Director

Cardiac Electrophysiology Fellowship Program

Assistant Professor of Medicine

Perelman School of Medicine

University of Pennsylvania

Philadelphia

Disclosures

DF declares that he has no competing interests.

Acknowledgements

Dr David Frankel would like to gratefully acknowledge Dr Mithilesh K. Das and Dr Douglas P. Zipes, the previous contributors to this monograph. 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 AF

stable: narrow complex (orthodromic AV reciprocating) tachycardia

stable: wide complex (antidromic AV 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: minimally symptomatic

following acute treatment: symptomatic

Contributors

Authors VIEW ALL 

David Frankel, 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

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Guidelines

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