- Email: [email protected]
MY APPROACH to the Athlete With Wolff-Parkinson-White Syndrome (WPW)*
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Available online at www.sciencedirect.com
www.elsevier.com/locate/tcm
MY APPROACH
MY APPROACH to the Athlete With Wolff-Parkinson-White Syndrome (WPW)*
WPW pattern
Aaron L. Baggish, MD
All athletes with WPW pattern require risk stratification for sudden cardiac death (SCD), which can occur when rapid atrial fibrillation is conducted down the anterograde accessory pathway at supraphysiologic heart rates culminating in ventricular fibrillation. We utilize a step-wise approach to SCD risk stratification. We begin by obtaining serial electrocardiograms to document persistence of the delta wave as intermittent loss of pre-excitation implies a longer accessory pathway refractory period and lower SCD risk. Next, we proceed to maximal effort exercise testing with the following technical considerations: • Careful attention to lead placement and application • Use of a stationary bicycle rather than treadmill to minimize motion artifact • Use of 50 mm/s paper speed to enhance delta wave visualization and diagnostic yield
Ankit B. Shah, MD, MPH There are two initial considerations during evaluation of an athlete with electrocardiographic evidence of ventricular preexcitation, a finding characterized by a shortened PR-interval (o120 ms) and slurring of the initial QRS complex, or “delta wave,” a pattern commonly referred to as Wolff-ParkinsonWhite syndrome (WPW). The first is to exclude concomitant structural (e.g., hypertrophic cardiomyopathy) or valvular (e.g., Ebstein’s anomaly) heart disease, thereby confirming the presence of isolated WPW. The second is to differentiate athletes with WPW pattern from athletes with WPW syndrome. Athletes with WPW pattern have pre-excitation but no symptoms suggestive of arrhythmia; athletes with WPW syndrome have pre-excitation and symptomatic arrhythmias involving their accessory pathway.
n
An abrupt loss of the delta wave during the physiologic tachycardia of exercise testing places the athlete at low risk for SCD. In these cases, the athlete can return to full athletic participation with the understanding that longitudinal follow-up is required as symptomatic, albeit non-life threatening, arrhythmias may develop in the future. If the delta wave persists throughout exercise testing, we refer athletes for a diagnostic electrophysiology study. Measurement of the anterograde conduction properties of the accessory pathway is done by evaluating the shortest pre-excited R-R interval (SPERRI) while in atrial fibrillation. A SPERRI of ≤250 ms indicates that the accessory pathway can conduct rapidly and places the individual at increased risk for SCD. We recommend that athletes with high-risk pathways undergo catheter ablation. In contrast, those with a SPERRI of 4250 ms are at low risk and can be longitudinally followed without ablation as described above.
First published on PracticeUpdate on July 3, 2017. Republished with permission.
http://dx.doi.org/10.1016/j.tcm.2017.09.005 1050-1738/& 2017 Elsevier Inc. All rights reserved.
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WPW syndrome Athletes with WPW syndrome and high-risk pathways are referred for catheter ablation. Catheter ablation of the accessory pathway has high cure rates (95–96%) when done in experienced centers, with low risk (o1%) of iatrogenic atrioventricular block during ablation of septal accessory pathways. Medical management with antiarrhythmic medications is less effective, can hinder athletic performance, and may have undesired side effects, including arrhythmia. Thus, medications are reserved for cases in which catheter ablation is contraindicated.
Masters athletes Management of an incidental finding of WPW pattern in a Masters athlete (435-years old) remains an area of
ME
D I C I N E
] (2017) ]]]–]]]
uncertainty. In theory, accessory pathway conduction slows with age and older athletes may inherently be at lower SCD risk given prior decades of event-free survival. However, there are no compelling primary data to guide management. As such, we engage with the athlete in a shared decisionmaking process in which both conservative and more aggressive options are presented and discussed on a caseby-case basis.
Aaron L. Baggish, MD, and Ankit B. Shah, MD, MPH Massachusetts General Hospital Harvard Medical School Yawkey 5B, 55 Fruit St Massachusetts General Boston, MA 02114 E-mail address: [email protected] (A.L. Baggish)
E N D S I N
C
A R D I O V A S C U L A R
M
E D I C I N E
] (2017) ]]]–]]]
Available online at www.sciencedirect.com
www.elsevier.com/locate/tcm
MY APPROACH
MY APPROACH to the Athlete With Wolff-Parkinson-White Syndrome (WPW)*
WPW pattern
Aaron L. Baggish, MD
All athletes with WPW pattern require risk stratification for sudden cardiac death (SCD), which can occur when rapid atrial fibrillation is conducted down the anterograde accessory pathway at supraphysiologic heart rates culminating in ventricular fibrillation. We utilize a step-wise approach to SCD risk stratification. We begin by obtaining serial electrocardiograms to document persistence of the delta wave as intermittent loss of pre-excitation implies a longer accessory pathway refractory period and lower SCD risk. Next, we proceed to maximal effort exercise testing with the following technical considerations: • Careful attention to lead placement and application • Use of a stationary bicycle rather than treadmill to minimize motion artifact • Use of 50 mm/s paper speed to enhance delta wave visualization and diagnostic yield
Ankit B. Shah, MD, MPH There are two initial considerations during evaluation of an athlete with electrocardiographic evidence of ventricular preexcitation, a finding characterized by a shortened PR-interval (o120 ms) and slurring of the initial QRS complex, or “delta wave,” a pattern commonly referred to as Wolff-ParkinsonWhite syndrome (WPW). The first is to exclude concomitant structural (e.g., hypertrophic cardiomyopathy) or valvular (e.g., Ebstein’s anomaly) heart disease, thereby confirming the presence of isolated WPW. The second is to differentiate athletes with WPW pattern from athletes with WPW syndrome. Athletes with WPW pattern have pre-excitation but no symptoms suggestive of arrhythmia; athletes with WPW syndrome have pre-excitation and symptomatic arrhythmias involving their accessory pathway.
n
An abrupt loss of the delta wave during the physiologic tachycardia of exercise testing places the athlete at low risk for SCD. In these cases, the athlete can return to full athletic participation with the understanding that longitudinal follow-up is required as symptomatic, albeit non-life threatening, arrhythmias may develop in the future. If the delta wave persists throughout exercise testing, we refer athletes for a diagnostic electrophysiology study. Measurement of the anterograde conduction properties of the accessory pathway is done by evaluating the shortest pre-excited R-R interval (SPERRI) while in atrial fibrillation. A SPERRI of ≤250 ms indicates that the accessory pathway can conduct rapidly and places the individual at increased risk for SCD. We recommend that athletes with high-risk pathways undergo catheter ablation. In contrast, those with a SPERRI of 4250 ms are at low risk and can be longitudinally followed without ablation as described above.
First published on PracticeUpdate on July 3, 2017. Republished with permission.
http://dx.doi.org/10.1016/j.tcm.2017.09.005 1050-1738/& 2017 Elsevier Inc. All rights reserved.
2
T
R E N D S I N
C
A R D I O V A S C U L A R
WPW syndrome Athletes with WPW syndrome and high-risk pathways are referred for catheter ablation. Catheter ablation of the accessory pathway has high cure rates (95–96%) when done in experienced centers, with low risk (o1%) of iatrogenic atrioventricular block during ablation of septal accessory pathways. Medical management with antiarrhythmic medications is less effective, can hinder athletic performance, and may have undesired side effects, including arrhythmia. Thus, medications are reserved for cases in which catheter ablation is contraindicated.
Masters athletes Management of an incidental finding of WPW pattern in a Masters athlete (435-years old) remains an area of
ME
D I C I N E
] (2017) ]]]–]]]
uncertainty. In theory, accessory pathway conduction slows with age and older athletes may inherently be at lower SCD risk given prior decades of event-free survival. However, there are no compelling primary data to guide management. As such, we engage with the athlete in a shared decisionmaking process in which both conservative and more aggressive options are presented and discussed on a caseby-case basis.
Aaron L. Baggish, MD, and Ankit B. Shah, MD, MPH Massachusetts General Hospital Harvard Medical School Yawkey 5B, 55 Fruit St Massachusetts General Boston, MA 02114 E-mail address: [email protected] (A.L. Baggish)