What medications should be started for a patient with Wolf-Parkinson-White (WPW) syndrome, a high Premature Ventricular Contraction (PVC) burden, and heart failure with reduced Ejection Fraction (EF)?

Management of Wolf-Parkinson-White Syndrome with High PVC Burden and Reduced Ejection Fraction

Beta-blockers should be initiated as first-line therapy for this 46-year-old male patient with Wolf-Parkinson-White syndrome, high PVC burden (19.4%), and reduced ejection fraction (44%). 1

Initial Medication Management

Foundation Therapy for Reduced Ejection Fraction

• Beta-blockers are recommended as cornerstone therapy for heart failure with reduced ejection fraction (HFrEF), which should be initiated as soon as possible after diagnosis 1, 2
• ACE inhibitors (or ARBs if intolerant) should be added to beta-blockers as part of the foundation therapy for HFrEF 3, 4
• Mineralocorticoid receptor antagonists (MRAs) should be added for patients who remain symptomatic despite ACE inhibitor and beta-blocker therapy 4
• Diuretics should be used for symptom relief if there is evidence of fluid retention 4

Special Considerations for WPW Syndrome

• For patients with WPW syndrome, catheter ablation of the accessory pathway is recommended, especially in symptomatic patients with pre-excited AF 1
• Avoid administration of amiodarone, adenosine, digoxin, or nondihydropyridine calcium channel antagonists in patients with WPW who have pre-excited AF, as these drugs can accelerate ventricular rate 1
• If the patient develops pre-excited AF with rapid ventricular response and is hemodynamically compromised, prompt direct-current cardioversion is recommended 1

Management of High PVC Burden

• High PVC burden (>10%) can contribute to or cause left ventricular dysfunction, a condition known as PVC-induced cardiomyopathy 5
• Catheter ablation of PVCs should be considered as it may improve left ventricular function in patients with PVC-induced cardiomyopathy 5, 6
• Beta-blockers can help reduce PVC burden and improve symptoms while waiting for definitive treatment 1

Comprehensive Treatment Algorithm

1. Initiate beta-blocker therapy:

   • Start at a low dose and titrate gradually to target dose while monitoring for bradycardia and hypotension 1
   • Beta-blockers help control ventricular rate and reduce PVC burden 1

2. Add ACE inhibitor therapy:

   • Begin with a low dose and titrate upward with monitoring of blood pressure and renal function 3
   • Target doses should be those shown to be effective in clinical trials 3

3. Refer for electrophysiology evaluation:

   • Catheter ablation of the accessory pathway is recommended for symptomatic patients with WPW syndrome 1
   • Ablation may improve left ventricular dyssynchrony and function 5
   • PVC ablation should be considered if PVC burden remains high despite medical therapy 5

4. Add mineralocorticoid receptor antagonist:

   • Add if patient remains symptomatic despite optimal doses of beta-blocker and ACE inhibitor 1, 4
   • Monitor potassium levels and renal function 4

5. Consider SGLT2 inhibitor:

   • As part of the four-pillar approach to HFrEF treatment 2

Important Cautions and Pitfalls

• Avoid certain antiarrhythmic drugs: Amiodarone, adenosine, digoxin, and nondihydropyridine calcium channel antagonists are contraindicated in WPW patients with pre-excited AF as they can accelerate ventricular rate and potentially cause ventricular fibrillation 1

• Monitor for proarrhythmia: Some antiarrhythmic drugs can worsen arrhythmias, especially in patients with structural heart disease 7, 8

• Do not delay definitive treatment: While medical therapy is important, catheter ablation of the accessory pathway should not be unnecessarily delayed, as it can lead to resolution of left ventricular dysfunction 5

• Regular follow-up: Monitor ejection fraction, symptoms, and PVC burden to assess response to therapy 1

• Avoid inotropic agents: Unless there is evidence of cardiogenic shock, inotropic agents should be avoided in chronic heart failure management 4

By following this approach, the patient's reduced ejection fraction and high PVC burden can be effectively managed while addressing the underlying WPW syndrome, potentially leading to improvement in cardiac function and reduction in symptoms.