What is the treatment for Wolff-Parkinson-White (WPW) tachycardia?

Treatment of Wolff-Parkinson-White (WPW) Tachycardia

Catheter ablation of the accessory pathway is the first-line therapy for symptomatic WPW patients, with success rates exceeding 95% and low complication rates. 1

Acute Management Based on Clinical Presentation

Hemodynamically Unstable Patients

• Immediate synchronized electrical cardioversion regardless of the type of tachycardia 2, 1
• Have defibrillation equipment immediately available and monitor ECG continuously during treatment 1

Hemodynamically Stable Patients with Orthodromic AVRT (narrow complex)

1. First-line: Vagal maneuvers (e.g., Valsalva maneuver) 2, 1
2. Second-line: Adenosine (3 mg rapid IV bolus, followed by 6 mg and then 12 mg if needed) 2
3. Third-line: If adenosine fails:
   • Synchronized cardioversion 2
   • Alternative pharmacologic options: IV beta-blockers or verapamil 2

Hemodynamically Stable Patients with Pre-excited AF (wide complex)

1. First-line: IV procainamide or ibutilide 2, 1
2. Second-line: Synchronized cardioversion if medications fail 2

Critical Caution

• NEVER administer AV nodal blocking agents (digoxin, diltiazem, verapamil, beta-blockers) in patients with suspected pre-excited AF as they can accelerate conduction through the accessory pathway, potentially precipitating ventricular fibrillation 2, 1

Definitive Management

• Catheter ablation is recommended for:
  • All symptomatic patients with WPW syndrome 1
  • Particularly those with pre-excited AF 1
  • Patients with syncope due to rapid heart rate 2, 1
  • Patients with accessory pathways with short refractory periods (<250 ms) 2, 1

Risk Stratification

• High-risk features warranting more aggressive management:
  • Short refractory period of accessory pathway (<250 ms) 1
  • Multiple accessory pathways 2, 1
  • History of pre-excited atrial fibrillation 1
  • Associated cardiac anomalies (e.g., Ebstein's anomaly) 1

Long-term Management If Ablation Not Performed

• Class IA or IC antiarrhythmic agents (flecainide, propafenone) to slow AP conduction 3
• Amiodarone may be considered for refractory cases 1
• Regular cardiac monitoring and risk reassessment 1

Post-Ablation Care

• ECG evaluation at 3 months and annually during the first years 1
• Patient education about symptoms requiring immediate medical attention 1
• Be aware that approximately 5-10% of patients may experience recurrence of accessory pathway conduction 1
• Ablation of the accessory pathway does not always prevent atrial fibrillation, especially in older patients, and additional pharmacological therapy may be required 1

The treatment approach for WPW tachycardia has evolved significantly, with catheter ablation now being the definitive treatment of choice due to its high success rate and favorable risk-benefit ratio. This has largely replaced long-term pharmacological management, which was previously the mainstay of treatment 4, 3.