Wolff-Parkinson-White syndrome EKG
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]
Overview
Overview
Wolff-Parkinson-White (WPW) pattern is characterized by ECG findings such as a short PR interval and a delta wave and wide QRS complex.WPW syndrome is the occurrence of tachycardia with or without associated symptoms in a subject with existing WPW pattern. WPW syndrome can present as an orthodromic or antidromic AVRT during which the delta wave no longer appears. Atrial fibrillation in a patient with WPW should be suspected when there is ECG findings of an irregularly irregular rhythm and absent P waves suggestive of atrial fibrillation in the context of a heart rate higher than 240 beats per minute.
WPW Pattern
WPW Pattern
- WPW pattern is characterized by the following typical EKG findings:
- Short PR interval: The PR interval is short because the ventricles begins to contract earlier than usual because of the electrical signal travels through the accessory pathway faster than the AV node.
- Wide QRS
- delta wave
- QRS alternans
- ST segment depression.
- Preexcitation and presence of delta waves typical of WPW syndrome or WPW pattern may either mimic myocardial infarction or may mask it.[1]
- Abolishment of delta waves may be necessary for the diagnosis of myocardial infarction on EKG.[2]
- Left posterolateral or lateral accessory pathways may mask inferior or anteroseptal myocardial infarction .[3]
- Posteroseptal accessory pathways may mask an anterior MI.[3]
- Right anteroseptal and anterolateral accessory pathways may mask inferior or anterolateral MI.[3]
- Abolishment of delta waves may be necessary for the diagnosis of myocardial infarction on EKG.[2]
For patient information, click here.
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Alonso Alvarado, M.D.
Synonyms and keywords: WPW syndrome, WPW pattern
EKG Classification | WPW Variants
Diagnosis
Approach | History and Symptoms | Electrocardiogram | EKG Examples | Other Diagnostic Studies
Treatment
Risk Stratification | Medical Therapy | Drug Prophylaxis | Management Algorithm
Related Chapters
Determining the location of the accessory pathway
Determining the location of the accessory pathway
| V1 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| _ | + | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Positive inferior leads | Positive inferior leads | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 0 | 1,2 | 3 | 3 | 1,2 | 0 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| V3 | V3 | V3 | Left lateral | Left posterolateral | V1/1 ratio | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| _ | + | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Right posterior | Right paraseptal | <1 | ≥1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| _ | + | Lead 2, Notched QS | Left posterolateral | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Right lateral | Nodo-Hisian | Yes | NO | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| _ | + | Deep coronary sinus | Left paraseptal | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Nodo-Hisian | Right atrium | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| The above algorithm adopted from 2019 ESC Guideline[4] |
|---|
WPW Syndrome
- WPW syndrome is the occurrence of tachycardia with or without associated symptoms in a subject with existing WPW pattern.[5]
- Several types of arrhythmia can occur in WPW syndrome such as AV reentrant tachycardia (AVRT), atrial fibrillation,or atrial flutter
the most common type of tachyarrhythmia is AVRT.[6]
- In orthodromic AVRT, the anterograde conduction (from the atrium to the ventricle) passes through theAV node and the retrograde conduction (from the ventricle to the atrium) passes through the accessory pathway.
- Orthodromic AVRT occurs in approximately 90 to 95% of WPW.
The EKG findings include the following:
- Regular rhythm
- Narrow QRS complexes
- Retrograde P wave following the QRS complex
- Long RP, short PR tachycardia
Antidromic AVRT
- The anterograde conduction (from the atrium to the ventricle) passes through the accessory pathway and the retrograde conduction (from the ventricle to the atrium) passes through the AV node.
- It apprears in less than 10% of WPW.
- The EKG findings may include the following:
- Regular rhythm
- Wide QRS complexes tachycardia
For patient information, click here.
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Alonso Alvarado, M.D.
Synonyms and keywords: WPW syndrome, WPW pattern
EKG Classification | WPW Variants
Diagnosis
Approach | History and Symptoms | Electrocardiogram | EKG Examples | Other Diagnostic Studies
Treatment
Risk Stratification | Medical Therapy | Drug Prophylaxis | Management Algorithm
Related Chapters
Atrial Fibrillation in WPW
- Atrial fibrillation in WPW syndrome is life-threatening because it might lead to ventricular tachycardia.
- The suggestive findings of [[antidromic AVRT] and rapid atrial fibrillation on the ECG may include the following:
- Irregularly irregular rhythm
- Absent of P wave
- Wide WRS
- Ventricular rate >240 beats per minute[7]
Shown below is an ECG depicting an irregularly irregular rhythm with wide QRS and absent P waves suggestive of atrial fibrillation in WPW syndrome.
Examples
Examples
Shown below is an EKG of Wolff-Parkinson-White syndrome demonstrating slurred upstroke of the QRS complex (>110 milli sec), resulting in a delta-wave (arrow). The EKG also shows a short PR interval.
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
Shown below is an EKG showing a slurred upstroke QRS complex which is best appreciated in the precordial leads and a PR interval of less than 120 ms (short PR interval) suggesting WPW syndrome.
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
Shown below is an EKG demonstrating a delta wave in leads V2, I, aVL, with wide QRS complexes and left axis deviation suggesting WPW syndrome.
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
Shown below is an EKG showing a short PR interval of less than 120 ms, delta waves in leads I, aVF, aVL and chest leads with wide QRS complexes indicating WPW syndrome.
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page
- For more EKG examples of Wolff-Parkinson-White syndrome click Wolff-Parkinson-White syndrome EKG examples here.
References
References
- ↑ Smolders L, Majidi M, Krucoff MW, Crijns HJ, Wellens HJ, Gorgels AP (2008). “Preexcitation and myocardial infarction: conditions with confusing electrocardiographic manifestations”. J Electrocardiol. 41 (6): 679–82. doi:10.1016/j.jelectrocard.2008.05.005. PMID 18602643.
- ↑ Liu R, Chang Q (2013). “The diagnosis of myocardial infarction in the Wolff-Parkinson-White syndrome”. Int J Cardiol. 167 (3): 1083–4. doi:10.1016/j.ijcard.2012.10.055. PMID 23157811.
- ↑ 3.0 3.1 3.2 Preminger MW, Callans DJ, Gottlieb CD, Marchlinski FE (1994). “Radiofrequency catheter ablation used to unmask infarction Q waves in Wolff-Parkinson-White syndrome”. Am Heart J. 128 (5): 1040–2. PMID 7942468.
- ↑ Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A (February 2020). “2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC)”. Eur Heart J. 41 (5): 655–720. doi:10.1093/eurheartj/ehz467. PMID 31504425.
- ↑ “Wolff-Parkinson-White Syndrome and Accessory Pathways”. Retrieved 1 April 2014.
- ↑ “ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary”. Retrieved 15 August 2013.
- ↑ Klein, George J.; Bashore, Thomas M.; Sellers, T. D.; Pritchett, Edward L. C.; Smith, William M.; Gallagher, John J. (1979). “Ventricular Fibrillation in the Wolff-Parkinson-White Syndrome”. New England Journal of Medicine. 301 (20): 1080–1085. doi:10.1056/NEJM197911153012003. ISSN 0028-4793.
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