Wolff-Parkinson-White (WPW) Syndrome




Background

Pathophysiology

History/Symptoms

Physical exam/Signs

Diagnostics

Treatment

  1. Initial/Prep
  2. Medical/Pharmaceutical
  3. Surgical/Procedural
Treatment Summary
Treatment Comment
If unstable-synchronized cardioversion Sedate if time allows.
Narrow-Complex Supraventricular Tachycardia

If stable-vagal maneuvers or carotid sinus massage

Do not perform carotid sinus massage if bruits are present.
Do not perform simultaneous bilateral carotid sinus massage.
First-line pharmacotherapy:
Adenosine, 6 mg (0.1 mg/kg) rapid IV bolus May administer a second dose of 12 mg (0.2 mg/kg) if no effect after 2 min.
No proven benefit to more than two doses or >20 mg total.
Second-line pharmacotherapy:
Calcium channel blockers  
Diltiazem 15 - 20 mg (0.25 mg/kg) IV, followed by a continuous infusion at 4 - 20 mg/h over 2 min May administer a second dose of diltiazem, 25 mg (0.35 mg/kg) IV in 15 min, if needed.
Contraindications to diltiazem use:
Hypotension.
Severe congestive heart failure.
Ventricular tachyarrhythmia.
or  
Verapamil, 2.5 - 5.0 mg IV over 2 min (3 min in older patients) May repeat dose of verapamil, 5 - 10 mg every 15 min, up to 20 mg.
Verapamil-induced hypotension may be prevented or treated with calcium chloride, 500–1000 mg, IV every 10 min as needed.
Contraindications to verapamil use:
Ventricular tachyarrhythmia.
Hypotension.
Presence of congestive heart failure.
COPD.
ß-Blockers  
Metoprolol, 5 mg, IV every 5 min up to 15 mg

 

or

 

Esmolol, 500 mcg/kg IV bolus, over 60 s, followed by an infusion starting at 50 mcg/kg/min May repeat esmolol bolus, 500 mcg/kg, if inadequate response after 2 to 5 min.
Increase infusion rate in increments of 50 mcg/kg/min after each bolus.
Maximal recommended infusion rate is 300 mcg/kg.
or  
Propranolol, 0.1 mg/kg divided in 3 equal doses given slowly 2 min apart May repeat once.
Contraindications to ß-blocker use:
Ventricular tachyarrhythmia.
Hypotension.
Severe congestive heart failure.
History of severe COPD, asthma.
Wide-Complex Supraventricular Tachycardia
Procainamide, 17 mg/kg IV over 30 min up to 50 mg/kg or 50% widening of QRS complex Avoid ß-blockers, calcium channel blockers, and adenosine.
Atrial Fibrillation
Synchronized cardioversion Sedate if time allows.
Procainamide, 17 mg/kg, IV over 30 min up to 50 mg/kg or 50% widening of QRS complex Avoid ß-blockers, calcium channel blockers, and adenosine.
Ibutilide

 

Weight <60 kg: 0.1 mL/kg (0.01 milligram/kg) IV over 10 min

 

Weight >60 kg: 1 mg (1 vial) IV over 10 min

 

Disposition

  1. Admit
  2. Discharge

Long-Term Management