Dr John Mandrola practices cardiac electrophysiology in Louisville, KY. He finished training at Indiana University in 1996. His practice encompasses catheter ablation, including an eight-year experience with AF ablation, device implantation, and consultative EP. Outside of the EP lab, Dr Mandrola's two hobbies include competitive cycling and writing. He has maintained a medical, fitness, and cycling blog, Dr John M, for the past two years.
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Joint PACES/HRS expert consensus statement offers guidance in the treatment of asymptomatic young patients with WPWMay 11, 2012 10:02 EDT
What is the right course of treatment for young people who are found to have asymptomatic Wolff-Parkinson-White (WPW)?
It's a timely topic, as increasing numbers of young people are being screened with ECGs as part of preparticipation sports evaluations.
For symptomatic WPW patients, the decision is easy--ablate the life-threatening accessory pathway. But it's not so clear for those patients yet to have an arrhythmia. On the one hand, the worry is that the youngsters' first event might be AF degenerating to VF as a result of the accessory pathway. On the other hand, the concern of overtreatment and exposing a patient to unnecessary harm from procedures looms large. Adding to the difficulty is the rarity of both WPW and the chance that it might cause cardiac arrest.
In a joint effort, and for the first time, the Pediatric and Congenital Electrophysiology Society (PACES) and Heart Rhythm Society (HRS) have released a new expert consensus statement concerning the treatment of asymptomatic young patients with WPW. The full list of recommendations can be read here.
In short, the experts suggest that patients with nonintermittent preexcitation that also persists during treadmill testing be risk-stratified by an invasive EP study. If the pathway has rapid conduction properties ablation should be performed. Other scenarios in which an aggressive approach is warranted include patients with structural heart disease or evidence of preexcitation-induced dyssynchrony. Ever timely is their agreement with AHA guidelines that medications used to treat attention-deficit disorder (ADD) may be prescribed for patients with asymptomatic WPW.
Why this statement is important
At least in adult cardiology, the old teaching suggests leaving asymptomatic WPW alone. Asymptomatic young people with WPW, however, are different. They have not yet lived long enough to prove that their accessory pathway is benign. This fact, along with recent studies on the natural history of WPW and the increasing safety of catheter-ablation techniques, confirm our clinical leaning that an EP study can help decide which patients to ablate. This paper used 21 years of age as a cutoff. An unanswered question remains at what age one has lived long enough with preexcitation to warrant a watchful-waiting strategy alone.