Please note: The following ECGs have all been recorded at 25 mm/sec and gain setting of 10 mm/mVe 26.1
A 54-year-old female walks into the Emergency Department complaining of palpitations for the past hour Her ECG is shown on page 8 (Figure 1). She has no electrolyte abnormalities.
a) Describe the rhythm disturbance. (20% marks)
b) How would you treat this rhythm disturbance? (10% marks)
c) Name two anti-arrhythmic drugs that are contra-indicated for this rhythm disturbance. (20% marks)
Atrial fibrillation with an accessory pathway
AF / SVT with aberrant conduction acceptable answer.(The rapid rate precludes AF with bundle branch block so no marks should be given for AF with bundle branch block).
Electrical cardioversion (flecainide, ibutilide, propafenone acceptable).
Digoxin, calcium channel blocker, beta-blockers, amiodarone, adenosine or other agents that preferentially block AV node and not accessory pathway.
This is WPW, in AF. The conduction rate is roughly 1:1.5; the QRS rate is about 180 to 200. It is hard to tell that its irregularly irregular. The QRS complexes will be a mixture of pre-excited delta-waving ones, and normal-looking narrow ones. If the accessory pathway has a short refractory period, it will conduct more often and therefore there will be more broad complexes than narrow ones. The shorter the refractory period of the accessory pathway, the broader the QRS. And the broader the QRS, the greater the chance of this thing degenerating into ventricular fibrillation.
Management of this acute arrhythmia has several options:
- vagal manoeuvres
- AVOID ASV node blocking drugs such as adenosine, digoxin, beta blockers and calcium channel blockers
- Procainamide, ibutilide or amiodarone are the only antiarrhytmics useful in WPW
- DC synchronised cardioversion
Flecainide or propafenone are used in long term management. Amiodarone also OK - but the side effect profile in long term use is not very nice for younger patients.
AV blockers are contraindicated in AF with WPW. The model answer to Question 3.1 from the first paper of 2009 lists digoxin and verapimil, although generally speaking all AV node blockers are at least relatively contraindicated in WPW.
- Digoxin decreases the refractory period of the accessory pathway
- Verapimil tends to accelerate the ventricular response to AF by a similar mechanism.
- Adenosine has a tendency to cause ventricular fibrillation
Wellens, Hein JJ, and Dirk Durrer. "Effect of digitalis on atrioventricular conduction and circus-movement tachycardias in patients with Wolff-Parkinson-White syndrome." Professor Hein JJ Wellens. Springer Netherlands, 2000. 63-68.
Gulamhusein, S. A. J. A. D., et al. "Acceleration of the ventricular response during atrial fibrillation in the Wolff-Parkinson-White syndrome after verapamil."Circulation 65.2 (1982): 348-354.
Munger, T. M., et al. "A population study of the natural history of Wolff-Parkinson-White syndrome in Olmsted County, Minnesota, 1953-1989."Circulation 87.3 (1993): 866-873.
Svenson, ROBERT H., et al. "Electrophysiological evaluation of the Wolff-Parkinson-White syndrome: problems in assessing antegrade and retrograde conduction over the accessory pathway." Circulation 52.4 (1975): 552-562.
Narula, Onkar S. "Wolff-Parkinson-White Syndrome A Review." Circulation 47.4 (1973): 872-887.
and, somewhat more recently...
Scheinman, Melvin M. "History of Wolff‐Parkinson‐White Syndrome." Pacing and clinical electrophysiology 28.2 (2005): 152-156.
Keating, L., F. P. Morris, and W. J. Brady. "Electrocardiographic features of Wolff-Parkinson-White syndrome." Emergency medicine journal 20.5 (2003): 491-493.