What is the management of a short PR interval in a 35-year-old asymptomatic man?

From the Guidelines

A short PR interval in an asymptomatic 35-year-old man likely represents Wolff-Parkinson-White (WPW) pattern, which requires no specific treatment if truly asymptomatic, but the patient should be referred to a cardiologist for confirmation with a 12-lead ECG and risk stratification, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1. The patient should be educated about potential symptoms to watch for, including palpitations, dizziness, syncope, or chest pain, which would warrant immediate medical attention.

• Regular follow-up every 1-2 years is recommended to monitor for symptom development.
• The patient should avoid medications that enhance AV nodal conduction like digoxin, verapamil, and diltiazem if arrhythmias develop.
• The short PR interval occurs because electrical impulses bypass the normal conduction pathway through an accessory pathway (Bundle of Kent), connecting the atria directly to the ventricles.
• This creates a potential circuit for reentrant tachycardias, though many individuals with this ECG finding remain asymptomatic throughout life.
• If symptoms develop, treatment options include antiarrhythmic medications like flecainide or propafenone, or catheter ablation of the accessory pathway, which is curative in over 95% of cases.
• According to the European Heart Journal, a short PR interval without delta wave has been reported as a normal variant of athlete’s ECG, but it needs a careful evaluation because it may reflect either a ventricular pre-excitation syndrome or an underlying structural heart disease 1.
• The 2015 ACC/AHA/HRS guideline also recommends that an EP study is reasonable in asymptomatic patients with pre-excitation to risk-stratify for arrhythmic events, and catheter ablation of the accessory pathway is reasonable in asymptomatic patients with pre-excitation if an EP study identifies a high risk of arrhythmic events 1.

From the Research

Management of Short PR Interval in a 35-year-old Man with No Symptoms

• The patient's condition suggests Wolff-Parkinson-White (WPW) syndrome, which is characterized by a short PR interval and the presence of an accessory electrical pathway in the heart 2.
• The management of WPW syndrome typically involves catheter ablation to eliminate the accessory pathway, which can help prevent the development of atrial fibrillation (AF) and other arrhythmias 3, 4.
• However, the decision to proceed with catheter ablation in an asymptomatic patient should be made on a case-by-case basis, taking into account the patient's individual risk factors and the potential benefits and risks of the procedure 5, 6.
• Studies have shown that patients with WPW syndrome who undergo successful catheter ablation have a significant reduction in the incidence of AF and other arrhythmias, and improved symptoms and quality of life 3, 4, 6.
• Nevertheless, some patients may still experience arrhythmia symptoms after ablation, which can be due to various factors such as recurrence of the accessory pathway, development of new arrhythmias, or other underlying conditions 6.

Risk Factors for Atrial Fibrillation in WPW Syndrome

• The presence of an accessory pathway with fast anterograde conduction is a significant risk factor for the development of AF in patients with WPW syndrome 2.
• Other risk factors include older age, male sex, and increased atrial vulnerability, which can be assessed through electrophysiologic studies and atrial endocardial catheter mapping 4, 5.
• Patients with a history of AF before ablation are more likely to experience recurrent AF after the procedure, highlighting the importance of careful patient selection and risk stratification 4, 6.

Monitoring and Follow-up

• Regular follow-up and monitoring are essential to detect any potential complications or recurrences after catheter ablation 3, 6.
• Patients should be educated on the signs and symptoms of arrhythmias and instructed to seek medical attention if they experience any palpitations, shortness of breath, or other concerning symptoms 6.