What are the treatment options for Wolff-Parkinson-White (WPW) syndrome?

From the Guidelines

Treatment for Wolff-Parkinson-White (WPW) syndrome should prioritize catheter ablation as the definitive treatment for symptomatic patients, with a success rate exceeding 95% 1. When managing WPW syndrome, it's crucial to consider the severity of symptoms and risk factors.

• For acute management of tachycardia episodes, vagal maneuvers like bearing down or carotid sinus massage may terminate the arrhythmia.
• If these fail, intravenous adenosine or verapamil can be used, but with caution due to potential risks.
• For patients with pre-excited atrial fibrillation (AF) and rapid ventricular response, intravenous procainamide or ibutilide is recommended to restore sinus rhythm or slow the ventricular rate in those who are not hemodynamically compromised 1.
• Catheter ablation of the accessory pathway is recommended in symptomatic patients with pre-excited AF, especially if the accessory pathway has a short refractory period that allows rapid antegrade conduction 1.
• Patients with WPW should avoid digoxin, verapamil, and diltiazem as chronic medications, as these can accelerate conduction through the accessory pathway during atrial fibrillation, potentially causing ventricular fibrillation.
• Even asymptomatic patients with WPW pattern on ECG should be evaluated for risk stratification, as some may benefit from prophylactic ablation if they have high-risk features like short refractory periods of their accessory pathway 1.

From the FDA Drug Label

In patients with Wolff-Parkinson-White (WPW) syndrome, propafenone reduces conduction and increases the effective refractory period of the accessory pathway in both directions

• Propafenone can be used for treatment of WPW syndrome as it reduces conduction and increases the effective refractory period of the accessory pathway in both directions 2.
• The drug slows conduction and consequently produces dose-related changes in the PR interval and QRS duration.
• Propafenone has been shown to be effective in suppressing recurrence of ventricular tachycardia and reducing the rate of single and multiple premature ventricular contractions (PVCs).

From the Research

Treatment Options for Wolff-Parkinson-White (WPW) Syndrome

• Radiofrequency catheter ablation is considered the first-line therapy for patients with symptomatic WPW syndrome, as it has been proven to be very effective and safe 3, 4, 5, 6.
• The success rate of radiofrequency catheter ablation in WPW patients is high, with a pooled effect estimate of 94.1% 6.
• The recurrence rate after radiofrequency catheter ablation is low, with a pooled effect estimate of 6.2% 6.
• The rate of complications associated with radiofrequency catheter ablation is also low, with a pooled effect estimate of 1% 6.

Asymptomatic WPW Syndrome

• The management of asymptomatic WPW syndrome is more controversial, and the decision to perform catheter ablation should be made on a case-by-case basis 3, 7.
• Invasive electrophysiological study and possible ablation of the accessory pathway may be offered to well-informed asymptomatic individuals with WPW if they are willing to trade the very small risk of subsequent sudden death or incapacity for a small immediate procedural risk of serious complications or death 3.
• Asymptomatic patients may require invasive risk stratification and possible catheter ablation for important social or professional reasons 3.

Medical Therapy

• Medications that prolong accessory pathway refractory periods, such as flecainide, propafenone, and amiodarone, can prevent rapid accessory pathway anterograde conduction in atrial tachycardias such as atrial fibrillation or flutter 5.
• Adenosine can be used to terminate the atrioventricular reciprocating tachycardia (AVRT) of WPW syndrome in emergencies 5.
• Class IA or IC antiarrhythmic agents can be used to slow accessory pathway conduction either with or without AV nodal blocking agents 5.