Atrial fibrillation in the Wolff-Parkinson-White syndrome: ECG recognition and treatment in the ED

Challenging the superiority of amiodarone for rate control in Wolff-Parkinson-White and atrial fibrillation

“…The failure to prevent an increased ventricular response leads the study to call for the establishment of the safety of amiodarone in WPW-AF [5]. The findings support the notion that amiodarone may not be the safe pharmacological treatment of choice for rate control in WPW-AF [2,4,5,13,16].…”

“…Furthermore, the review notes that out of ten patients with WPW-AF who had ventricular tachydysrhythmias after antidysrhythmic drug administration, seven of the cases involved IV amiodarone [16]. Fengler et al, in a case report, caution against the use of amiodarone as well, stating that IV amiodarone usage in WPW-AF is documented to cause ventricular rate acceleration leading to ventricular fibrillation [4]. Additionally, Schützenberger et al [13] caution against the use of amiodarone in WPW-AF presenting a case report of an increased ventricular response secondary to accelerated conduction via the accessory pathway.…”

“…Additionally, Fengler et al [4] favor the use of procainamide in WPW-AF, stating procainamide prolongs the effective refractory period and slows antegrade and retrograde conduction in the AP. Procainamide has risks as well, including a significant side-effect profile, namely hypotension, QT-interval prolongation, and contraindications for patients with compromised cardiovascular function [3,4].…”

“…However, it is unclear whether this endorsement takes into consideration that amiodarone can cause ventricular fibrillation in a small but significant number of cases [2,16], or that amiodarone is simply not efficacious in a number of wide-complex tachycardia cases [3,8]. Despite procainamide's potential for WPW-AF control, it has significant side effects, including hypotension [3,4]. This risk can be anticipated and mitigated with a slow infusion of procainamide plus an infusion of intravenous fluids.…”

Wolff-Parkinson-White Syndrome Presenting After a Motorcycle Accident

“…Acutely, people with WPW who are experiencing tachyarrhythmias may require synchronized electrical cardioversion if their condition is critical (e.g., they are hypotensive or lethargic with altered mental status); if they are stable, medical treatment may be used [11]. Patients with AF and rapid ventricular response are often treated with amiodarone or procainamide to stabilize their heart rate.…”