Wolff-Parkinson-White syndrome EKG

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

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.[1] 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.[2] 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 220 beats per minute.

WPW Pattern

  • WPW pattern is characterized by the following typical ECG findings:
  • Other findings that can be present in a subject with an accessory pathway include QRS alternans and ST segment depression.
  • Preexcitation and presence of delta waves typical of WPW syndrome or WPW pattern may either mimic acute and chronic MI or may mask it[3]
    • Abolishment of delta waves may be necessary for the diagnosis of MI to be made on ECG[4]
    • Left posterolateral or lateral accessory pathways may mask inferior or anteroseptal MI[5]
    • Posteroseptal accessory pathways may mask an anterior MI[5]
    • Right anteroseptal and anterolateral accessory pathways may mask inferior or anterolateral MI[5]

Determining the location of the accessory pathway

Check lead V1
Negative delta wave in V1 = right ventricle Positive delta wave im V1= left ventricle
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
Posteroseptal Right free wall Anteroseptal Posteroseptal Lateral

WPW Syndrome

WPW syndrome is the occurrence of tachycardia with or without associated symptoms in a subject with existing WPW pattern.[6] 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.[2]

Orthodromic AVRT

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. Orthodromic AVRT occurs in approximately 90 to 95% of WPW.
The EKG findings include:

SVT.jpg

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 include:

Wide complex tachy.jpg

Atrial Fibrillation in WPW

Atrial fibrillation in WPW syndrome is life-threatening because it might lead to ventricular tachycardia. The suggestive findings on the ECG include:

  • Irregularly irregular rhythm
  • Absent P wave
  • Wide WRS
  • Ventricular rate >220 beats per minute

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

Wpw with afib.PNG

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.

Rhythm WPW.png

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.

Wolf Parkinson White syndrome.png

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.

WPW syndrome 1.jpg

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.

WPW syndrome 2.jpg

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


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

References

  1. "Wolff-Parkinson-White Syndrome and Accessory Pathways". Retrieved 1 April 2014.
  2. 2.0 2.1 "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.
  3. 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.
  4. 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.
  5. 5.0 5.1 5.2 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.
  6. "Wolff-Parkinson-White Syndrome and Accessory Pathways". Retrieved 1 April 2014.



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