Can a Patient with Wolff-Parkinson-White Syndrome Take Lexapro (Escitalopram)?
Yes, a patient with WPW syndrome can take Lexapro (escitalopram), as it is not contraindicated in WPW and does not accelerate conduction through the accessory pathway—the primary concern in this condition.
Understanding the Key Concern in WPW
The critical issue in WPW syndrome is avoiding medications that can accelerate conduction through the accessory pathway during atrial fibrillation, which can precipitate ventricular fibrillation and sudden cardiac death. 1
Absolutely contraindicated medications in WPW with pre-excited atrial fibrillation include:
- IV amiodarone 1
- Adenosine 1, 2
- Digoxin 1, 3
- Nondihydropyridine calcium channel antagonists (diltiazem, verapamil) 1, 3
- Beta-blockers (during pre-excited AF) 3
Why Lexapro is Safe in WPW
Escitalopram (Lexapro) is a selective serotonin reuptake inhibitor (SSRI) that does not affect AV nodal conduction or accessory pathway conduction. 4 It does not appear on any guideline list of contraindicated medications for WPW syndrome. 1, 3, 2
The mechanism of harm in WPW involves:
- Medications that slow AV nodal conduction while leaving the accessory pathway unaffected, thereby preferentially directing impulses through the dangerous accessory pathway during atrial fibrillation 3
- Escitalopram does not have these electrophysiologic effects 4
Important Caveats for All Medications in WPW
Risk stratification matters when considering any medication:
- Patients with symptomatic tachycardia have a 2.2% annual risk of sudden cardiac death versus 0.15-0.2% in asymptomatic WPW patients 3, 5
- Short RR intervals (<250 ms) between pre-excited beats during atrial fibrillation indicate higher risk 3, 5
- Multiple accessory pathways or posteroseptal location increase risk 3
For any patient with WPW requiring medication:
- Obtain a baseline ECG before starting new medications 5
- Be aware that approximately one-third of WPW patients may develop atrial fibrillation 3
- Consider definitive treatment: catheter ablation has >95% success rate with <1-2% complication rate in experienced centers and eliminates the need for lifelong medication restrictions 3, 2
Clinical Bottom Line
Lexapro does not interact with the accessory pathway conduction that defines WPW syndrome and can be safely prescribed. 4 The focus should remain on avoiding the specific AV nodal blocking agents listed above, particularly if the patient develops pre-excited atrial fibrillation. 1, 3