Treatment-accessory pathways (wolff-parkinson-white)

(Heart Rhythm 2012;9:1006, Circ 2014;130:e199 & 2016;133:e506)

• AVRT (orthodromic): vagal, βB, CCB; care w/ adenosine (can precip AF); have defib ready
• AF/AFL w/ conduction down accessory pathway: need to Rx arrhythmia and ↑ pathway refractoriness. Use procainamide, ibutilide, or DCCV; avoid CCB, βB, amio, dig, & adenosine, b/c can ↓ refractoriness of pathway → ↑ vent. rate → VF (Circ 2016;133:e506).
• Long term: RFA if sx; if not candidate for RFA, then AAD (IA, III) or CCB/βB. Consider RFA if asx but AVRT or AF inducible on EPS (NEJM 2003;349:1803) or if rapid conduction possible (✓ w/ EPS if pre-excitation persists during exercise testing) Risk of SCD related to how short RR interval is in AF (eg, <250 ms) and if SVT inducible