Wolff-Parkinson-White syndrome: lessons learnt and lessons remaining

Area of Science:

• Cardiology
• Electrophysiology

Background:

• Wolff-Parkinson-White pattern is an electrocardiographic finding characterized by an accessory atrioventricular pathway causing a short P-R interval and a delta wave.
• This pattern can be asymptomatic or associated with arrhythmias like orthodromic reciprocating tachycardia and, rarely, sudden death.

Observation:

• Historically, risk stratification for sudden death included symptoms and a shortest pre-excited R-R interval <250 ms during induced atrial fibrillation.
• Current guidelines suggest invasive evaluation for asymptomatic patients if pre-excitation persists during exercise testing, though accuracy is under investigation.

Findings:

• The prevalence of asymptomatic Wolff-Parkinson-White pattern necessitates improved risk assessment methods.
• Intermittent pre-excitation, previously considered low-risk, may pose a significant risk.
• The role of isoproterenol in risk stratification requires further study.

Implications:

• Accurate risk stratification is crucial for guiding management decisions, including catheter ablation, in asymptomatic individuals with Wolff-Parkinson-White pattern.
• Further research is needed to refine risk assessment strategies, particularly for patients with intermittent pre-excitation and to evaluate the utility of pharmacologic stress testing.