eMedicine Specialties > Emergency Medicine > Cardiovascular

Wolff-Parkinson-White Syndrome

Author: Thomas J Hemingway, MD, Attending Physician, Department of Emergency Medicine, Wilcox Memorial Hospital
Coauthor(s): Eric Alexander Savitsky, MD, Associate Clinical Professor of Medicine, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles Medical Center; Mel Herbert, MD, MBBS, Assistant Professor of Medicine and Nursing, Department of Emergency Medicine, Olive View-University of California at Los Angeles Medical Center
Contributor Information and Disclosures

Updated: Dec 2, 2009

Introduction

Background

Preexcitation was defined by Durrer et al in 1970 with the following statement, "Preexcitation exists, if in relation to atrial events, the whole or some part of the ventricular muscle is activated earlier by the impulse originating from the atrium than would be expected if the impulse reached the ventricles by way of the normal specific conduction system only."1 In preexcitation, atrial impulses bypass the typical electrical pathway that conducts via the atrioventricular node and activates the ventricular myocardium directly via an accessory pathway.Of the various preexcitation syndromes, the most common is Wolff-Parkinson-White (WPW) syndrome. Emergency departments should be familiar with this syndrome and the proper treatment of its associated dysrhythmias to minimize morbidity and mortality.

Pathophysiology

Accessory pathways or connections between the atrium and ventricle are the result of anomalous embryonic development of myocardial tissue bridging the fibrous tissues that separate the two chambers. This allows for electrical conduction between the atria and ventricles at sites other than the atrioventricular node (AVN). Passage through accessory pathways circumvent the usual conduction delay between the atria and ventricles, which normally occurs at the AVN and predisposes the patient to develop tachydysrhythmias.

Although dozens of locations for bypass tracts can exist in preexcitation, including atriofascicular, fasciculoventricular, intranodal, or nodoventricular, the most common bypass tract is an accessory atrioventricular (AV) pathway otherwise known as a Kent bundle. This is the anomaly seen in Wolff-Parkinson-White syndrome. Conduction through a Kent bundle can be anterograde, retrograde, or both. Another common preexcitation syndrome, Lown-Ganong-Levine (LGL), also has an accessory pathway (the James fibers), which connect the atria serially to the His bundle. The end result is the same, preexcitation and a predisposition to the development of tachydysrhythmias. Fortunately, the treatment of LGL parallels that of Wolff-Parkinson-White syndrome, and they are discussed together.

Frequency

International

Wolff-Parkinson-White syndrome affects approximately 0.15-0.2% of the general population. Of these individuals, 60-70% have no other evidence of heart disease.

Mortality/Morbidity

Death from Wolff-Parkinson-White syndrome occurs secondary to the associated dysrhythmias or from mistreatment of these dysrhythmias with inappropriate medications. Little data are available regarding the mortality rate of such dysrhythmias, but most studies report the incidence of sudden death in the 0-4% range.

Sex

Men (60-70% cases) are affected more often than women. Typically, those affected are young, otherwise healthy individuals.

Age

Although this disease affects people of all ages, it is most commonly recognized in children and young adults presenting to the ED with a dysrhythmia. Conduction speed in the accessory pathway appears to attenuate with age.

Clinical

History

  • Patients with Wolff-Parkinson-White (WPW) syndrome may present with anything from mild chest discomfort or palpitations with or without syncope to severe cardiopulmonary compromise or cardiac arrest.
  • Occasionally, electrocardiographic evidence of disease is discovered on routine electrocardiography (ECG), independent of a concurrent tachydysrhythmia.
  • Patients commonly present with rapid heart rates in the 250 beats per minute (bpm) range, often with associated hypotension.
  • Many patients are not aware of their underlying condition.

Physical

Wolff-Parkinson-White syndrome has no specific examination features except for those that may accompany symptomatic dysrhythmias.

  • Many young patients appear minimally symptomatic (eg, palpitations, weakness, mild dizziness) despite exceedingly fast heart rates.
  • Upon physical examination, the patient may be cool, diaphoretic, and hypotensive.
  • Crackles in the lungs are common because the rapid heart rate may cause pulmonary vascular congestion due to congestive heart failure.

More on Wolff-Parkinson-White Syndrome

Overview: Wolff-Parkinson-White Syndrome
Differential Diagnoses & Workup: Wolff-Parkinson-White Syndrome
Treatment & Medication: Wolff-Parkinson-White Syndrome
Follow-up: Wolff-Parkinson-White Syndrome
Multimedia: Wolff-Parkinson-White Syndrome
References
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References

  1. Durrer D, Schuilenburg RM, Wellens HJ. Pre-excitation revisited. Am J Cardiol. Jun 1970;25(6):690-7. [Medline].

  2. Fengler BT, Brady WJ, Plautz CU. Atrial fibrillation in the Wolff-Parkinson-White syndrome: ECG recognition and treatment in the ED. Am J Emerg Med. Jun 2007;25(5):576-83. [Medline].

  3. [Guideline] American Heart Association. Advanced Cardiac Life Support. 2005.

  4. [Guideline] ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Dec 13 2005;112(24 Suppl):IV1-203. [Medline].

  5. Szumowski L, Orczykowski M, Derejko P, et al. Predictors of the atrial fibrillation occurrence in patients with Wolff-Parkinson-White syndrome. Kardiol Pol. Sep 2009;67(9):973-8. [Medline].

  6. Shapira AR. Catheter ablation of supraventricular arrhythmias and atrial fibrillation. Am Fam Physician. Nov 15 2009;80(10):1089-94. [Medline].

  7. Conover MB. Diagnosis and management of arrhythmias associated with Wolff-Parkinson-White syndrome. Crit Care Nurse. Jun 1994;14(3):30-9; quiz 40-1. [Medline].

  8. Delacretaz E. Clinical practice. Supraventricular tachycardia. N Engl J Med. Mar 9 2006;354(10):1039-51. [Medline].

  9. Gaita F, Giustetto C, Riccardi R, et al. Wolff-Parkinson-White syndrome. Identification and management. Drugs. Feb 1992;43(2):185-200. [Medline].

  10. Garratt C, Antoniou A, Ward D, et al. Misuse of verapamil in pre-excited atrial fibrillation. Lancet. Feb 18 1989;1(8634):367-9. [Medline].

  11. Garratt CJ, Griffith MJ, O'Nunain S, Ward DE, Camm AJ. Effects of intravenous adenosine on antegrade refractoriness of accessory atrioventricular connections. Circulation. Nov 1991;84(5):1962-8. [Medline].

  12. Herbert ME, Votey SR. Adenosine in wide-complex tachycardia. Ann Emerg Med. Jan 1997;29(1):172-4. [Medline].

  13. [Guideline] Kinsara AJ. 2000 Guidelines for Cardiopulmonary Resuscitation Emergency Cardiovascular Care. Circulation. Aug 28 2001;104(9):E45. [Medline].

  14. Shah CP, Gupta AK, Thakur RK, et al. Adenosine-induced ventricular fibrillation. Indian Heart J. Mar-Apr 2001;53(2):208-10. [Medline].

  15. Sharma AD, Klein GJ, Yee R. Intravenous adenosine triphosphate during wide QRS complex tachycardia: safety, therapeutic efficacy, and diagnostic utility. Am J Med. Apr 1990;88(4):337-43. [Medline].

  16. Stahmer SA, Cowan R. Tachydysrhythmias. Emerg Med Clin North Am. Feb 2006;24(1):11-40, v-vi. [Medline].

  17. Tintinalli JE. Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill; 2004.

  18. Wellens HJ, Brugada P, Penn OC. The management of preexcitation syndromes. JAMA. May 1 1987;257(17):2325-33. [Medline].

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Further Reading

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Keywords

Wolff-Parkinson-White syndrome, WPW syndrome, preexcitation syndrome, atrioventricular reentrant tachycardia, atrioventricular nodal reentrant tachycardia, paroxysmal supraventricular tachycardia, supraventricular tachycardia, heart disease, treatment, diagnosis, symptoms

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Contributor Information and Disclosures

Author

Thomas J Hemingway, MD, Attending Physician, Department of Emergency Medicine, Wilcox Memorial Hospital
Thomas J Hemingway, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Eric Alexander Savitsky, MD, Associate Clinical Professor of Medicine, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles Medical Center
Eric Alexander Savitsky, MD is a member of the following medical societies: Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Mel Herbert, MD, MBBS, Assistant Professor of Medicine and Nursing, Department of Emergency Medicine, Olive View-University of California at Los Angeles Medical Center
Mel Herbert, MD, MBBS is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Theodore J Gaeta, DO, MPH, FACEP, Clinical Associate Professor, Department of Emergency Medicine, Joan and Sanford Weill Medical College at Cornell University; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine
Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: Alliance for Clinical Education, American College of Emergency Physicians, Clerkship Directors in Emergency Medicine, Council of Emergency Medicine Residency Directors, New York Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gary Setnik, MD, Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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