eMedicine Specialties > Cardiology > Arrhythmias

Wolff-Parkinson-White Syndrome: Follow-up

Author: Vibhuti N Singh, MD, MPH, FACC, FSCAI, Director, Suncoast Cardiovascular Center; Chair, Cardiology Division and Cath Labs, Department of Medicine, Bayfront Medical Center; Clinical Assistant Professor, Division of Cardiology, University of South Florida College of Medicine
Coauthor(s): Rakesh K Sharma, MD, FACC, Adjunct Associate Professor of Medicine and Cardiology; University of Arkansas for Medical Sciences, Medical Center of South Arkansas
Contributor Information and Disclosures

Updated: Aug 24, 2009

Follow-up

Further Inpatient Care

• Patients with WPW syndrome who are admitted to the hospital after initiation of medical treatment in the emergency department may require further evaluation and management as follows:
  • Continuous telemetry monitoring to look for resurgence of tachyarrhythmia and the degree of control of the ventricular rate in those with atrial fibrillation
  • Initiation, dose adjustment, and maintenance of long-term antiarrhythmic drugs for preventing recurrences (However, patients generally undergo ablation.)
  • Laboratory evaluation and correction of electrolyte and metabolic abnormalities that may have acted as triggers
• Evaluation for associated underlying structural cardiac defects, such as Ebstein anomaly and hypertrophic cardiomyopathy, is as follows:
  • EP evaluation of patients who meet the indications, including the following:
    • To diagnose and locate accessory pathways and the reentrant pathways or sites of origin of SVTs
    • To define appropriate therapy
    • To test the results of therapy
    • To enable electrocardiographically guided therapy such as RF ablation
  • RF ablation for patients who are candidates for such therapy, including the following:
    • Patients with symptomatic tachycardia who cannot tolerate drug therapy or whose conditions are resistant to such therapy
    • Patients who have atrial fibrillation with a rapid ventricular response via a bypass tract who cannot tolerate drug therapy or whose conditions are resistant to such therapy
    • Patients who have AV reentrant tachycardia or atrial fibrillation with rapid ventricular rates found during EP studies
    • Asymptomatic patients whose profession, insurability, mental well-being, or responsibility to public safety may be affected by unpredictable occurrence of tachyarrhythmias
    • Patients with a family history of sudden cardiac death
• Monitor drug use.
• Carefully monitor for proarrhythmias, especially when procainamide, quinidine, amiodarone, or sotalol are initiated. A few days of inpatient telemetry monitoring, including determination of QT interval lengthening on ECG readings, is required for these agents. An increase in the QT interval of 25% or greater should be avoided.
• Surgical ablation is recommended in certain patients, including the following:
  • Patients in whom RF catheter ablation fails
  • Patients who will be undergoing concomitant cardiac surgery
  • Patients with atrial tachycardias who have multiple foci (sometimes)

Further Outpatient Care

• Patients need to continue antiarrhythmic therapy as prescribed. If symptoms related to tachyarrhythmias recur, patients should inform the physician.
• Arrange follow-up visits to assess for the recurrence of arrhythmia, the effectiveness of antiarrhythmic therapy, and adverse effects of medications.
  • Follow-up ECG or Holter monitoring may be needed to assess for changes in QT duration and the recurrence of arrhythmias or proarrhythmias.
  • Patients who take amiodarone require careful periodic monitoring for adverse effects and organ toxicity, including thyroid function tests, ophthalmic examination, pulmonary function tests, and hepatic function tests.
• Patients who undergo EP studies, RF ablation, or surgical ablation may require monitoring of wound care following hospital discharge. Further follow-up care to assess for the recurrence of arrhythmia is also needed.
• Patients with underlying structural heart disease, such as the Ebstein anomaly, may require follow-up care by a specialist pediatric cardiologist.
• If a patient with WPW syndrome dies suddenly, siblings and first-degree relatives should be screened for preexcitation.
• Unless curative ablation has been performed, patients should refrain from participating in competitive sports.
• Routine EP studies are not recommended following RF ablation solely to ensure that the ablation was curative, unless patients become symptomatic.
• Asymptomatic patients with only the ECG findings of preexcitation should be seen at frequent intervals and should not undergo any aggressive EP evaluation or pharmacologic or ablative therapy unless they become symptomatic or their profession, insurability, mental well-being, or the safety of the public may be affected by unpredictable occurrence of tachyarrhythmias.

Inpatient & Outpatient Medications

• Adenosine
• Digoxin (not recommended for WPW syndrome in adults)
• Propranolol
• Verapamil
• Quinidine
• Procainamide
• Amiodarone
• Sotalol

Transfer

Certain patients with WPW syndrome must be transferred to a tertiary facility for comprehensive evaluation and management by a cardiac electrophysiologist, which may include EP studies or ablative therapy. Such patients include those presenting with any of the following:

• Sudden death
• Syncope
• Significant symptomatic tachyarrhythmias
• Uncertain diagnosis in those with wide-complex tachycardia
• Associated structural heart disease, eg, Ebstein anomaly, cardiomyopathy, mitral valve prolapse.
• WPW syndrome who have a family history of sudden death
• Asymptomatic but with WPW syndrome who are in professions in which spontaneous occurrence of tachyarrhythmia may jeopardize public safety, cause much mental anguish, or influence insurability
• Atrial fibrillation or flutter

Deterrence/Prevention

• WPW syndrome is largely congenital or hereditary. No particular method exists to eliminate the possibility of developing accessory pathways. In the future, genetic recognition and counseling may become a useful tool.
• Fortunately, the majority of patients with ECG findings of preexcitation do not develop tachyarrhythmias.
• Patients who present with tachyarrhythmic symptoms require drug therapy to prevent further episodes. Such long-term therapy may include the use of amiodarone, sotalol, quinidine and propranolol, and verapamil and diltiazem on a regular basis.
• If the procedure is successful, patients who have undergone ablative treatment are usually cured of the disease and are not at risk for further tachyarrhythmias.

Complications

• Tachyarrhythmia
• Palpitations
• Dizziness or syncope
• Sudden cardiac death
• Complications of drug therapy (eg, proarrhythmia, organ toxicity)
• Complications associated with invasive procedures and surgery
• Recurrence

Prognosis

• Patients with only preexcitation on their ECG findings who are asymptomatic generally have a very good prognosis. Most of these patients do not develop symptoms in their lifetime.
• Patients with a family history of sudden cardiac death or significant symptoms of tachyarrhythmias or cardiac arrest have worse prognoses. However, once definitive therapy is performed, including curative ablation, the prognosis is once again excellent.
• Asymptomatic patients should not be evaluated by EP testing unless they are in a high-risk profession. Risk stratification is not generally needed for asymptomatic patients.

Patient Education

• Patient education is of paramount importance in patients with WPW syndrome. This is especially true in asymptomatic young patients who have been told of their abnormal ECG results. Reassurance and periodic follow-up care of such patients is necessary.
• Educate patients who are being treated with drug therapy thoroughly regarding the disease and the type of medications they are taking. Such patients must be taught the following:
  • How to recognize disease recurrence
  • How to perform vagal maneuvers, when needed
  • To keep their follow-up appointments
  • To identify the adverse effects of antiarrhythmic drugs
  • To avoid competitive sports
  • To learn about ablative options and the indications for ablation, should they become candidates in future
• Patients with WPW syndrome should also educate their family members, and their siblings should be screened for preexcitation.
• For excellent patient education resources, visit eMedicine's Heart Center. Also, see eMedicine's patient education article Supraventricular Tachycardia.

Miscellaneous

Medicolegal Pitfalls

• Evaluate patients presenting with symptomatic tachycardia (SVT or wide-complex tachycardia) for the presence of preexcitation on the ECG results.
• Evaluate patients with WPW syndrome for the presence of very short refractory periods because these patients carry higher probabilities of developing symptoms or complications. These patients also respond poorly to drug therapy. Identify these patients, even if asymptomatic, and treat them aggressively using EP evaluations and ablative therapy.

Special Concerns

• Children with symptomatic WPW syndrome who undergo RF ablation sustain myocardial damage or injury. How this damaged myocardium will change as children grow is still not known.
• Evaluate patients with Ebstein anomaly for multiple accessory pathways. During EP studies and ablation, all such pathways should be recognized and treated.

• Search for CME/CE on This Topic »

• Wolff-Parkinson-White Syndrome (Emergency Medicine)
• Supraventricular Tachycardia, Wolff-Parkinson-White Syndrome (Pediatrics: Cardiac Disease and Critical Care Medicine)
• Programmed Electrical Stimulation (Cardiology)
• Ventricular Fibrillation (Pediatrics: Cardiac Disease and Critical Care Medicine)

• Supraventricular Tachycardia Overview
• Supraventricular Tachycardia Causes
• Heart Center
• Supraventricular Tachycardia Symptoms
• Supraventricular Tachycardia Treatment

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