Expert Statement Released to Guide Management of Asymptomatic Patients With Wolff-Parkinson-White
May 14, 2012 – The Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS) release the "PACES/HRS Expert Consensus Statement on the Management of the Asymptomatic Young Patient with a Wolff-Parkinson-White (WPW, Ventricular Pre-Excitation) Electrocardiographic Pattern." The expert consensus statement presented at Heart Rhythm 2012, the Heart Rhythm Society’s 33rd Annual Scientific Sessions, provides first-of-its-kind clinical practice guidelines on the evaluation and management of asymptomatic young patients with a WPW electrocardiographic pattern. This is also the first collaboration between PACES and HRS.
Patients with the WPW syndrome may have palpitations, dizziness or fainting from an extra electrical pathway (circuit) in the heart. The condition can lead to episodes of rapid heart rate or tachycardia.[i] Patients may be asymptomatic despite having an electrocardiogram with a WPW pattern. According to the consensus statement, it is estimated to occur in anywhere from one to three people per 1,000. Identification of the truly asymptomatic patient with WPW is difficult, but it is estimated that approximately 65 percent of adolescents with a WPW pattern on resting electrocardiograms (ECGs) are asymptomatic.
As ECGs have become more common for screening prior to sports participation, medical procedures and initiation of some medications, the number of asymptomatic individuals, especially children and adolescents, with WPW has increased. And while catheter ablation is best to eliminate the risk of sudden death in the asymptomatic child with WPW, optimum management of these patients is unclear.
Members from PACES and HRS formed a committee that performed a formal literature review and then weighed the strength of the evidence for or against an observational strategy or a particular procedure in the evaluation and management of asymptomatic patients with WPW. The resulting consensus statement is directed at all healthcare professionals who treat young patients with WPW. For the specific purpose of this statement, the young patient is defined as being between eight and 21 years of age, an age span routinely cared for by pediatricians and pediatric cardiologists.
“While it is a small chance that an asymptomatic young person could end up having a life-threatening heart event, the number is not zero. Yet, catheter ablation for every child who has ever had a WPW pattern is also not the answer,” said task force chair and lead author of the statement Mitchell I. Cohen, M.D., FACC, FHRS, section chief, pediatric cardiology and director, pediatric electrophysiology and pacing at Phoenix Children's Hospital in Arizona and clinical associate professor at the University of Arizona School of Medicine. “We felt we could provide all clinicians who treat adolescents with guidance, whether it’s the emergency room physician or the family physician. Taking a ‘wait and see approach’ is not the answer.”
The worldwide writing group with members from both societies deemed the following as the evidence-based recommended practice for asymptomatic young patients with WPW electrocardiographic pattern:
1. An exercise stress test, when the child is old enough to comply, if he or she exhibits persistent pre-excitation.
2. In patients with intermittent pre-excitation, establish oversight by cardiologist who should provide counseling and symptom awareness.
3. In those whose non-invasive testing shows persistent or uncertain loss of pre-excitation, perform diagnostic transesophageal or intracardiac electrophysiology study. Based on the results of the electrophysiology study, there may be either a recommendation for an ablation or continued awareness and observation for symptoms.
4. Patients with WPW and structural heart disease are at risk for both atrial tachycardia and atrioventricular (AV) reciprocating tachycardia and should consider ablation.
5. Asymptomatic patients with WPW and ventricular dysfunction secondary to dyssynchronous contractions may consider ablation.
6. Young patients with asymptomatic WPW may be prescribed attention deficit disorder (ADD) medications. This recommendation follows the American Heart Association (AHA) guidelines.
The consensus statement has also been endorsed by the American College of Cardiology (ACC), the AHA, the American Academy of Pediatrics (AAP) and the Canadian Heart Rhythm Society (CHRS), and will be published in the June 2012 edition of HeartRhythm.
Heart Rhythm 2012 is the most comprehensive educational program for heart rhythm professionals, featuring more than 250 educational sections and more than 130 innovative products and services. The Heart Rhythm Society’s Annual Scientific Sessions have become the must-attend event of the year, allowing the exchange of new vital ideas and information among colleagues from every corner of the globe.
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