Guideline sources The following summarized guidelines for the evaluation and management of pre-excitation syndrome are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC 2020), the American Heart Association (AHA/HRS/ACC 2016), and the Heart Rhythm Society (HRS/PACES 2012). 1 2 3 Guidelines 1. Diagnostic investigations Electrocardiography: As per ESC 2020 guidelines, consider obtaining noninvasive evaluation of the conducting properties of the accessory pathway in asymptomatic patients with pre-excitation. C As per AHA 2016 guidelines, elicit any of the following in both asymptomatic and symptomatic patients with pre-excitation to identify patients at low risk of developing rapid conduction over the pathway: abrupt loss of conduction over the pathway during exercise testing in sinus rhythm B intermittent loss of pre-excitation during ECG or ambulatory monitoring. B As per HRS 2012 guidelines: Consider obtaining exercise stress testing in the evaluation of pediatric patients old enough to comply with the testing, if the ambulatory ECG exhibits persistent pre-excitation. C https://web.pathway.md/diseases/recWdcSGbkL7DNKDr 1/4 6/29/23, 11:24 PM Pre-excitation syndrome Pathway Recognize that the ECG and exercise testing may be difficult to interpret in pediatric patients with subtle pre-excitation. 2. Diagnostic procedures Electrophysiology study: As per ESC 2020 guidelines, conduct an electrophysiology study using isoprenaline to risk stratify asymptomatic patients with pre-excitation having high-risk occupations/hobbies, and those participating in competitive athletics. B Show 2 more As per AHA 2016 guidelines: Conduct an electrophysiology study in symptomatic patients with pre-excitation to risk- stratify for life-threatening arrhythmic events. B Consider conducting an electrophysiology study in asymptomatic patients with pre- excitation to risk-stratify for arrhythmic events. C As per HRS 2012 guidelines, consider performing invasive risk stratification (transesophageal or intracardiac) to assess the shortest pre-excited R-R interval in AF in pediatric patients, if the noninvasive testing does not demonstrate clear and abrupt loss of pre-excitation. C 3. Therapeutic procedures Catheter ablation: As per ESC 2020 guidelines, perform catheter ablation in asymptomatic patients if electrophysiology testing using isoprenaline identifies high-risk properties, such as: shortest pre-excited RR interval during AF 250 ms accessory pathway effective refractory period 250 ms multiple accessory pathways inducible accessory pathway-mediated tachycardia. B Show 4 more As per AHA 2016 guidelines, consider performing catheter ablation of the accessory pathway in asymptomatic patients with pre-excitation if: an electrophysiology study identifies a high risk of arrhythmic events (including rapidly conducting pre-excited AF) the presence of pre-excitation precludes specific employment (such as with pilots). C As per HRS 2012 guidelines, consider performing catheter ablation in young patients with shortest pre-excited R-R interval 250 ms in AF (increased risk for sudden cardiac death), taking into account the procedural risk factors based on the anatomical location of the pathway. C Show 5 more 4. Specific circumstances https://web.pathway.md/diseases/recWdcSGbkL7DNKDr 2/4 6/29/23, 11:24 PM Pre-excitation syndrome Pathway Patients with pre-excited atrial fibrillation (pharmacologic management): Consider administering IV formulations of the following medications for acute management of hemodynamically stable patients with pre-excited AF: ibutilide C procainamide C flecainide C propafenone. C Do not use IV amiodarone in patients with pre-excited AF. D Patients with pre-excited atrial fibrillation (synchronized electrical cardioversion): Perform synchronized direct current cardioversion for acute management of hemodynamically unstable patients with pre-excited AF. B Perform synchronized direct current cardioversion for acute management of hemodynamically stable patients with pre-excited AF if drug therapy fails to convert or control the tachycardia. B Patients with ADHD: recognize that patients with WPW ECG pattern and ADHD may be prescribed ADHD medications. 5. Follow-up and surveillance Observation: As per ESC 2020 guidelines, consider obtaining clinical follow-up in asymptomatic patients with pre-excitation and a low-risk accessory pathway at invasive risk stratification. C As per AHA 2016 guidelines, consider observing asymptomatic patients with pre-excitation, without further evaluation or treatment. C Clinical findings Symptoms ECG findings Chest pain Delta wave Dizziness Lown-ganong-levine pattern Lightheadedness WPW triad Palpitations QRS duration Pre-syncope PR duration Syncope References 1. Josep Brugada, Demosthenes G Katritsis, Elena Arbelo et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology ESC . Eur Heart J. 2020 Feb 1;41 5 655 720. Open https://web.pathway.md/diseases/recWdcSGbkL7DNKDr 3/4 6/29/23, 11:24 PM Pre-excitation syndrome Pathway 2. Richard L Page, Jos A Joglar, Mary A Caldwell et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016 Apr 5;133 14):e471 505. Open 3. Pediatric and Congenital Electrophysiology Society PACES , Heart Rhythm Society HRS , American College of Cardiology Foundation ACCF et al. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson-White WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society PACES and the Heart Rhythm Society HRS . Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation ACCF , the American Heart Association AHA , the American Academy of Pediatrics AAP , and the Canadian Heart Rhythm Society CHRS . Heart Rhythm. 2012 Jun;9 6 1006 24. Open https://web.pathway.md/diseases/recWdcSGbkL7DNKDr 4/4