Wolff Parkinson White Syndrome in an Elderly Patient Undergoing Electrophysiological Evaluation A Clinical and Pharmaceutical Perspective

Abstract

WPW syndrome is a disorder of cardiac conduction defined by existence of ventricular pre-excitation due to presence of anomalous atrioventricular conduction pathway. Often identified in young people, it may continue throughout old age and give rise to clinically meaningful arrhythmias. We present a 75-yr old man who was referred to our unit with symptomatic tachyarrhythmia which required electrophysiological study and in patient management and treatment with adequate drugs. This case emphasizes role of appropriate risk stratification and choice of pharmacotherapy and management in elderly with WPW syndrome. Early diagnosis and management are best method to avoid major complication..

Keywords

Introduction

Wolff-Parkinson-White (WPW) syndrome refers to an atrioventricular (AV) conduction abnormality with an abnormal AV conduction system, often the Bundle of Kent, which allows electrical impulse to bypass the AV node and activate both atria and ventricles at the same time. The result is characteristic electrocardiogram (ECG) patterns including Shortened PR interval, widened QRS complexes with presence of a delta wave and QRS duration over 0.12ms.

Prevalence of Ventricular pre-excitation in the general population is estimated to be 0.1-0.3%. The occurrence of tachycardia among WPW pattern is found to occur in some patients; atrioventricular re-entrant tachycardia, atrial fibrillation or sometimes Ventricular Fibrillation is thus defined as WPW syndrome. WPW pattern commonly appears in children or young adults but in certain occasions it could present with tachycardia in elderly patients. Older patients with WPW pattern may still develop potentially lethal arrhythmias so prompt investigation is indicated. Electrophysiology study (EPS) is still the pillar for investigation to characterize pathway properties and anticipate risk of induction of life-threatening arrhythmias.

We report the case of WPW pattern in a 75-year-old patient, which requires in-hospital EPS study.

CASE PRESENTATION

The case reports of a 75-year-old man who was bought to the Emergency Department due to the complaints of palpitation and tachycardia in the last few weeks without any symptoms of fainting. No personal or family history was recorded towards structural heart disease and no known drug allergies. On admission, his vitals are stable. The examination revealed haemodynamically stable patient and had no signs of heart failure. His cardiovascular system had no murmur and heart rate was regular. ECG showed a short PR interval with widening of the QRS complex, a slurred upstroke indicating delta wave characteristic of WPW. Serum electrolytes, blood count, RFT, and LFT are within normal limits.

A thorough pre-procedural evaluation was undertaken:

ECG monitoring

Basic blood tests

Coagulation studies were sent.

Pre- Cath checklist and Informed consent

He was taken to cardiac Cath lab, was placed in electrophysiology room and was given iv fluids. He was also given iv cefuroxime as prophylactic antibiotic therapy 3 times a day. Programmable electrical stimulation of atrium was performed which confirmed WPW and accessory pathway conduction and inducibility of an SVT. There were no untoward effects of procedure. Vitals were stable and he was transferred to coronary care unit for post EPS monitoring. He was then managed with the following:

IV fluids

ECG monitoring

Electrolyte correction as necessary

Monitoring for recurrence of arrhythmias

He was discharged in a stable condition to be assessed in cardiology out-patient clinic and potential cardiac catheter ablation if necessary.

DISCUSSION

WPW syndrome is identified with the existence of accessory atrioventricular conduction pathway which serves a path from atria to ventricles bypassing slow AV node. Compared to AV node, which is a slowly conducting and decremental path, accessory path is rapidly conducting and decremental. Abnormal conduction of this kind is associated with re-entrant tachycardias and life-threatening arrhythmias. AVRT is the most common type of SVT found in-patients. Other types include atrial fibrillation, which is what the WPW patients in this scenario must worry about because their ventricular rate would become incredibly fast as the conduction speed through the AV node is not affected and this may lead to VF. Shortest pre-excited RR interval<250ms is linked with a higher incidence of VF with atrial fibrillation. WPW patients, particularly those presenting with symptoms should be assessed of risk. In contrast with non-invasive testing (e.g., Stress test, Holter) that might give some information about the conduction property, EP study is considered a "gold standard" to confirm the accessory path and to evaluate the ventricular response. 8. The acute management in unstable arrhythmia patients comprises intravenous Amiodarone, Procainamide or synchronized electrical cardioversion. For suitable candidates who are intended for radical therapy, catheter ablation which is known to be associated with high success rate and low morbidity can provide the curative option and can be applied in elderly people.

From the perspective of clinical pharmacists, the most vital information required for management of WPW is:

Reviewing of potential proarrhythmic agents and discontinuation.

On-going assessment for electrolyte abnormalities particularly K+ and Mg++.

Identification and Management of Drug Interactions.

Patient education about medication and symptoms of the early warning.

This case has highlighted that the elderly could have WPW pattern without been detected and could present with asymptomatic arrhythmia and are likely to undertake workup for WPW syndrome. Age should not be an argument against EPS if clinically indicated.

CONCLUSION

WPW pattern is an important etiology for SVTs and can present in the elderly. Early detection of WPW syndrome can help prevent complications, the definitive treatment being EPS. Clinical Pharmacy input also contributes to the efficient and safe management of patients with WPW.

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