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13-05-2012 | Article

Consensus statement addresses cardiac abnormality in young patients

Abstract

Consensus Statement (PDF)

MedWire News: The Pediatric and Congenital Electrophysiology Society (PACES) and Heart Rhythm Society (HRS) have issued an expert consensus statement on the care of young, asymptomatic patients with a Wolff-Parkinson-White (WPW) electrocardiographic (ECG) pattern.

Patients with WPW have an accessory electrical pathway in the heart. Although the majority have normal cardiac anatomy, WPW has also been diagnosed in patients with myopathic and structural heart disease.

Symptoms may include palpitations, dizziness, and syncope, and depending on the age at presentation, supraventricular tachycardia. Many young patients, however, are asymptomatic, and are diagnosed only after they undergo ECG required by many school districts prior to participation in organized sports.

WPW can be effectively treated with radiofrequency ablation (RFA) delivered by catheter, but invasive techniques may not always be appropriate for younger patients, according to lead author Mitchell Cohen (Phoenix Children's Hospital, Phoenix, Arizona).

"While it is a small chance that an asymptomatic young person could end up having a life-threatening heart event, the number is not zero. Yet catheter ablation for every child who has ever had a WPW pattern is also not the answer. We felt we could provide all clinicians who treat adolescents with guidance, whether it's emergency room physicians of the family physician. Taking a 'wait and see approach' is not the answer," he said in a press statement.

The expert consensus statement, which has been endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation, the American Heart Association, the American Academy of Pediatrics, and the Canadian Heart Rhythm Society, contains eight recommendations for the management of asymptomatic patients aged 8-21 years with the WPW ECG pattern. 1.

Perform an exercise stress test if the ambulatory ECG exhibits persistent pre-excitation. 2.

Use invasive risk stratification (transesophageal or intracardiac) to assess the shortest pre-excited R-R interval in atrial fibrillation in patients in whom noninvasive testing fails to demonstrate clear and abrupt loss of pre-excitation. 3.

Consider catheter ablation in young patients with a measurement of the shortest pre-excited R-R interval (SPERRI) of 250 ms or less in atrial fibrillation, who are at increased risk for sudden cardiac death (SCD). 4.

Ablation may be safely deferred in young patients with a SPERRI greater than 250 ms in atrial fibrillation, who are at lower risk for SCD. 5.

Consider catheter ablation in previously asymptomatic patients who subsequently develop cardiovascular symptoms such as syncope or palpitations. 6.

Consider ablation, regardless of the anterograde characteristics of the accessory pathway, in asymptomatic patients with a WPW ECG pattern and structural heart disease. 7.

Consider ablation in asymptomatic patients with a WPW ECG pattern and ventricular dysfunction secondary to dyssynchronous contractions, regardless of anterograde characteristics of the bypass tract. 8.

Medications for attention deficit/hyperactivity disorder (ADHD) may be prescribed for asymptomatic patients with a WPW ECG, in accordance with American Heart Association guidelines stating that ADHD medications may be used in this setting after cardiac evaluation and with intermittent monitoring and supervision of a pediatric cardiologist.

MedWire (www.medwire-news.md) is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2012

By Neil Osterweil