Wolff-Parkinson-White syndrome medical therapy

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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]; Rim Halaby, M.D. [3]

Overview

Wolff-Parkinson-White (WPW) syndrome patients who are hemodynamically unstable, as reflected by the presence of hypotension, cold extremities, mottling or peripheral cyanosis, or those who present with ischemic chest pain or decompensated heart failure should urgently undergo direct current cardioversion.[1] The medical therapy of hemodynamically stable patients with WPW syndrome depends on the type of the tachycardia. When the ECG findings suggest orthodromic AVRT, the patient should be managed similarly to patients with supreventricular tachycardia followed by the sequential administration of adenosine, verapamil and procainamide in case of failure to improve. Among patients with antidromic AVRT, AV nodal blocking agents should be avoided and patients should be treated with either procainamide, ibutilide or flecainide.[2] In case of WPW syndrome with atrial fibrillation in hemodynamically stable patients, procainamide, ibutilide or flecainide can be administered.[3] The long term treatment of patients with WPW syndrome depends on the presence or absence of symptoms and their severity. Patients who have poorly tolerated symptomatic WPW syndrome should undergo [[catheter ablation.[2]

Acute Treatment

Atrioventricular Reentrant Tachycardia (AVRT)

  • AVRT is one of the type of tachycardia that can occur in patients with WPW pattern. AVRT can be either orthodromic or antidromic, and the distinction between the two types is important because it dictates the choice of treatment.

Hemodynamically Unstable Patients

  • WPW syndrome patients with AVRT who are hemodynamically unstable, as reflected by the presence of hypotension, cold extremities, mottling or peripheral cyanosis, or those who present with ischemic chest pain or decompensated heart failure should urgently undergo direct current cardioversion. The shocks should be delivered as follows:
    • Narrow regular rhythm: synchronized electrical cardioversion, 50-100 Joules
    • Narrow irregular rhythm: synchronized electrical cardioversion, 120-200 Joules biphasic or 200 Joules monophasic
    • Wide regular rhythm: synchronized electrical cardioversion, 100 Joules
    • Wide irregular rhythm: unsynchronized electrical cardioversion, 200-360 Joules monophasic, or 100-200 Joules biphasic[1]

Orthodromic AVRT in Hemodynamically Stable Patients

The sequence of therapeutic decisions is summarized below.

Treatment of Orthodromic AVRT in Hemodynamically Stable Patients
Perform the following maneuvers (Class I, Level of Evidence B):
Vagal maneuvers

Carotid sinus massage
Valsalva maneuver

If not effective initiate the IV AV nodal blocking agent adenosine:
❑ Administer adenosine 6 mg IV (bolus) (Class I, Level of Evidence A)

❑ If the initial dose is not effective, administer a second dose of 12 mg, repeated a second time if required
Contraindications: asthma, second degree AV block or third degree AV block unless a pacemaker is present

If adenosine is not effective:
❑ Administer verapamil 5 to 10 mg (0.075 to 0.15 mg/kg body weight) IV boluses of over 2 minutes (Class I, Level of Evidence A)

❑ Give 30% of the dose in case of hepatic impairment
❑ Monitor for prolonged PR interval in case of renal impairment
Contraindications: severe left ventricular dysfunction, hypotension or cardiogenic shock

If verapamil is not effective:
❑ Administer procainamide, 100 mg infusion diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes (Class I, Level of Evidence B)

❑ Give until the arrhythmia is suppressed or up to 500 mg
❑ Wait 10 minutes or longer to administer new dosage
❑ Dosage should be adjusted for the individual patient in case of renal impairment
Contraindications: third degree AV block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes
OR
❑ Administer propranolol, metoprolol, and esmolol

Antidromic AVRT in Hemodynamically Stable Patients

Treatment of Antidromic AVRT in Hemodynamically Stable Patients
Medication Dosage Notes
Procainamide 100 mg infusion diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes ❑ Give until the arrhythmia is suppressed or until 500 mg has been administered

❑ Wait 10 minutes or longer to administer new dosage
Contraindications: third degree AV block, lupus erythematosus, idiosyncratic hypersensitivity, torsades de pointes

Ibutilide 1 mg IV infusion over 10 minutes ❑ Repeat the dosage if the tachycardia continues

Contraindications: hypersensitivity to ibutilide or any component of the formulation, QTc >440 msec

Flecainide 50 mg every 12 hours ❑ Increase 50mg BID every four days until efficacy is achieved

❑ Maximum dose recommended for supraventricular tachycardia is 300 mg/day
Contraindications: pre-existing second degree AV block or third degree AV block , right bundle branch block associated with a left hemiblock unless a pacemaker is present, cardiogenic shock, hypersensitivity to the drug

Atrial Fibrillation

Hemodynamically Unstable Patients

In hemodynamically unstable patients, urgent direct current cardioversion should be performed.[1]

Hemodynamically Stable Patients

Long Term Treatment

The long term management of patients with WPW syndrome depends on the presence or absence of syndrome. Among symptomatic patients, the tolerability of the symptoms guides the choice of the long term treatment.[2]

Asymptomatic Patients

Symptomatic Patients

Contraindicated medications

WPW SYNDROME is considered an absolute contraindication to the use of the following medications:

References

  1. 1.0 1.1 1.2 "Part 8: Adult Advanced Cardiovascular Life Support". Retrieved 3 April 2014.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.
  3. 3.0 3.1 American College of Cardiology Foundation. American Heart Association. European Society of Cardiology. Heart Rhythm Society. Wann LS, Curtis AB; et al. (2013). "Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines". Circulation. 127 (18): 1916–26. doi:10.1161/CIR.0b013e318290826d. PMID 23545139.



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