Question of the Week # 225

225 ) A 40 year-old man presents to office for routine follow-up visit. His past medical history is significant for hypertension for which he is on Hydrochlorthiazide. He denies any chest pain, palpitatations, shortness of breath or syncope. He is a journalist by occupation. A routine EKG  is obtained and is shown below:

Which of the following is the most appropriate managment of this patient?

A) Beta-blocker

B) Catheter ablation

C) Diltiazem

D) Observation

E) Electrophysiological studies


13 Responses

  1. b

  2. B) Catheter ablation

  3. D or B?…..No symptoms, no family history of sudden death.?

    Asymptomatic patients with only the ECG findings of preexcitation should be seen at frequent intervals.

    The diagnosis of Wolff-Parkinson-White (WPW) syndrome is typically made with formal electrocardiographic (ECG) monitoring in conjunction with clues from the history and physical examination.

    Evaluate patients presenting with symptomatic tachycardia (supraventricular tachycardia [SVT] or wide-complex tachycardia) for the presence of preexcitation on the 12-lead ECG results, and consider consultation with a cardiac electrophysiologist.

    Evaluate patients with WPW syndrome for the presence of very short refractory periods because these patients carry higher probabilities of developing symptoms or complications. The patients also respond poorly to drug therapy. Identify these patients, even if asymptomatic, and treat them aggressively using electrophysiologic study (EPS) and ablative therapy.

    Asymptomatic patients with a family history of sudden cardiac death (SCD) or with ventricular preexcitation but no spontaneous dysrhythmia who engage in high-risk occupations or activities and in whom knowledge of the electrophysiologic properties of the AP or inducible tachycardia may help determine recommendations for further activities or therapy

    Patients with ventricular preexcitation who are undergoing cardiac surgery for other reasons

    In consultation with an electrophysiologist, consideration of prophylactic ablation of an AP in an asymptomatic patient, which may reduce the risk of SCD and does reduce the onset and incidence of SVT in children

    If AF is induced during either an intraesophageal or an electrophysiologic study, the shortest RR interval between 2 consecutive preexcited QRSs is measured. If the interval is less than 220 ms, then the risk of sudden death due to VF is believed to be high. Specifically, according to 1 study, the most discriminating predictor of VF in patients with WPW syndrome was the shortest RR interval during AF of 172 ± 23 ms (versus 230 ± 50 ms).[12] Those patients were considered to be at high risk for developing VF and sudden death should AF occur.

    A study of asymptomatic children with WPW pattern who underwent EPS for risk stratification reported that a high proportion of subjects experienced sustained AVRT, AF, or both, with the shortest RR between 2 consecutive preexcited QRSs being 230-250 ms (mean, 237.5 ± 9.6 ms).

    The authors concluded that those results may be indicative of the necessity of RF ablation in all asymptomatic individuals with WPW pattern.

    So, my answer is…….B

  4. B) Catheter ablation

    Hypertension is a risk factor for a-Fib —> High Ventricular rate (conduction through accessory pathway )—> Sudden Cardiac Death

  5. Answer is D observation .

    Why would you do an electrophysiological studies on a patient who has no prior symptoms of WPW . the findings on ECG is accidental .
    Patient is low risk : Journalist . Even if you find something on EPS : would you do anything differently ? EPS has risk of complication . I would not risk my patient doing EPS without solid indication .

    EPS is the next step if : patient has episode of Palpitation and syncope admitted to the ED .

    You will never do an catheter ablation just because you have asymptomatic WPW findings on ECG . Would you want me to poke your heart if there’s no absolute indication to it ?

    Just my 2 cents .

  6. The most recent guidelines of the American College of Cardiology and the European Society of Cardiology on the management of asymptomatic WPW patients suggest restricting catheter ablation of APs to those in high-risk occupations and professional athletes—ie, to advise on the basis of individual considerations. Catheter ablation in asymptomatic pre-excitation was classified as a IIA indication with a B level of evidence.

  7. one should start with noninvasive studies (exercise, Holter, effect of a pharmacological intervention) to identify the low-risk patient because of a long anterograde RP of the AP. In patients not showing block in their AP during these noninvasive studies, esophageal pacing can be performed to determine the anterograde RP of the AP and the ability to induce sustained arrhythmias. If arrhythmias can be induced, benefits and risk of an invasive investigation and catheter ablation should be based on individual considerations such as age, gender, occupation, and athletic wishes. This should be discussed with the patient or,

  8. ans e

  9. E:)

  10. I applied guidelines for the children
    The guideline writers recommend the following:

    If a child is old enough to comply, an exercise stress test to look for persistent preexcitation is “reasonable.” Clear loss of preexcitation at physiologic heart rates is associated with lower risk of sudden death due to accessory pathways.
    Where noninvasive testing shows persistent or uncertain loss of preexcitation, diagnostic transesophageal or intracardiac electrophysiology studies are warranted. Recommendations, based on test results, include ablation or continued awareness and observation for symptoms.
    Ablation is a “reasonable” consideration in young people with a shortest preexcited RR interval (SPERRI) 250 ms are lower risk, and ablation may be deferred.
    Patients deemed low risk who subsequently develop symptoms like syncope or palpitations may be eligible for ablation.
    WPW in the setting of structural heart disease increases risk for both atrial tachycardia and atrioventricular (AV) reciprocating tachycardia. Patients can be considered for ablation.
    Ablation may also be considered in asymptomatic patients with WPW who have ventricular dysfunction secondary to dyssynchronous contractions.

  11. EPS with RF ablation is now the treatment of choice for most adults and many children with symptomatic WPW syndrome, as well as many asymptomatic patients. This approach has largely supplanted surgical and DC current modalities because it is more efficacious, safe, and cost-effective. With successful EPS and RF ablation, patients are usually cured of the disease and are not at risk for further tachyarrhythmias related to the AP.

    Answer: E

  12. I’m confused. 😦

    Most people with the WPW pattern on ECG who do not experience tachycardia do not need treatment. These patients may never develop symptoms and, in many cases, conduction via the accessory pathway spontaneously disappears as the patient grows older.

    However, some asymptomatic patients with a WPW ECG pattern (such as people with a high-risk occupation or professional athletes) are advised to undergo additional testing, including electrophysiologic testing, to determine if the accessory pathway is associated with a high risk of sudden cardiac arrest.

    Patients with WPW syndrome require treatment when or if they have an episode of tachycardia due to the serious potential risks of the tachycardia. Treatment focuses on stopping the tachycardia and preventing it from recurring.

    This patient is 40 years old. Perhaps his accessory pathway should have disappeared?

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