Application of the 2015 ACC/AHA/HRS guidelines for risk stratification for sudden death in adult patients with asymptomatic pre‐excitation

Abstract

The management of the asymptomatic pre-excited patient largely hinges on risk stratification and individual patient considerations and choice. A high threshold to treat patients may lead to a small overall risk of death while a low threshold clearly leads to increased invasive testing and ablation with associated cost and procedural risk. A firm recommendation to uniformly assess all by electrophysiology study or, alternatively, reassure all is inappropriate and unjustified by data as reflected in the recent guideline recommendations. The use of noninvasive and invasive parameters to identify the potentially at-risk individual with surveillance for symptoms in those comfortable with this approach or ablation for those choosing this alternative for individual reasons remains the cornerstone of best practice.

Risk assessment of pre-excitation: Atrial fibrillation versus atrial flutter

“…The transition of atrial fibrillation to atrial flutter with very rapid sustained conduction may offer a possible explanation for the higher incidence of sudden death in young patients with WPW syndrome compared to older patients. 8 …”

Coexistence of atrioventricular accessory pathways and drug‐induced type 1 Brugada pattern

“…The mechanism of sudden cardiac arrest and sudden death in most patients with WPW syndrome and WPW “pattern” is thought to be due to AF with preexcitation resulting in a very rapid ventricular rate that can lead to VF . Electrophysiologic risk factors for the development of VF include presence of spontaneous and/or inducible AVRT, presence of multiple accessory pathways, shortest preexcited R‐R interval (<250 ms) during preexcited AF and a short (≤250 ms) antegrade effective refractory period of the accessory pathway . Successful catheter ablation of AV‐APs in resuscitated patients with WPW syndrome has been reported to prevent recurrences of cardiac arrest .…”

“…Patients with AV-APs have an increased propensity to develop AF. 19 Male gender, older age, multiple AV-APs, presence of preexcitation and spontaneous AVRT, presence of structural heart disease, intrinsic atrial vulnerability due to developmental defects, and arrhythmogenic pulmonary veins have been proposed as the underlying mechanisms for this propensity. On the other hand, the prevalence of AF in patients with BrS has been reported to be higher than in the general population of the same age.…”

N‐terminal pro‐B‐type natriuretic peptide and D‐dimer combined with left atrial diameter to predict the risk of ischemic stroke in nonvalvular atrial fibrillation

“…Patients with NVAF included all three types of AF (paroxysmal AF, persistent AF, and permanent AF) with arbitrary durations. 18 , 19 IS was defined as neurological deficits caused by focal brain, spinal cord, or retinal infarction. 20 BMI was defined as weight (kg) divided by the square of height (m) (kg/m 2 ).…”

“…NVAF was defined as AF without mechanical valves or moderate‐to‐severe mitral stenosis (usually resulting from rheumatism). Patients with NVAF included all three types of AF (paroxysmal AF, persistent AF, and permanent AF) with arbitrary durations 18,19 . IS was defined as neurological deficits caused by focal brain, spinal cord, or retinal infarction 20 .…”