Medical therapy of arrhythmias associated with Wolff-Parkinson-White syndrome

Arrhythmia	Treatment options	Contraindicated therapies
Orthodromic AV reentrant tachycardia
Acute termination*	Unstable patients: Synchronized cardioversion Stable patients: First line: Vagal maneuvers Second line: IV adenosine Third line: IV verapamil OR IV diltiazem Other therapies: IV procainamide OR IV beta blocker; synchronized cardioversion if other therapies are ineffective or not feasible
Chronic prevention^¶	First line: Catheter ablation of the accessory pathway Second line: Oral flecainide or propafenone in the absence of structural or ischemic heart disease Third line: Oral IA antiarrhythmic agent OR oral amiodarone
Antidromic AV reentrant tachycardia
Acute termination*	Unstable patients: Synchronized cardioversion Stable patients (if CERTAIN of the diagnosis): Same progression of therapies as acute termination of orthodromic AVRT^Δ Stable patients (if NOT certain of the diagnosis): IV procainamide, synchronized cardioversion if procainamide is ineffective or not available^Δ	Adenosine, verapamil, diltiazem, beta blockers, digoxin should all be avoided if NOT certain of diagnosis
Chronic prevention^¶	First line: Catheter ablation of the accessory pathway Second line: Oral flecainide or propafenone in the absence of structural or ischemic heart disease Other therapies: Oral IA antiarrhythmic agent OR oral amiodarone	Digoxin Beta blockers Verapamil, diltiazem
Pre-excited atrial fibrillation
Acute termination*	Unstable patients: Synchronized cardioversion Stable patients: First line: IV ibutilide or IV procainamide Other therapies: IC antiarrhythmic agent or dofetilide; synchronized cardioversion if other therapies are ineffective or not available	Amiodarone Digoxin Beta blockers Adenosine Verapamil, diltiazem
Chronic prevention^¶	First line: Catheter ablation or the accessory pathway Second line: Oral flecainide or propafenone in the absence of structural or ischemic heart disease Third line: Oral IA antiarrhythmic agent OR oral amiodarone	Oral digoxin

AVRT: atrioventricular reciprocating tachycardia; IV: intravenous; class IC: flecainide, propafenone; class IA: quinidine, procainamide, disopyramide.
* Cardioversion is indicated if hemodynamically unstable or drugs are ineffective.
¶ Ablation of the accessory pathway is generally preferred to cure the arrhythmia.
Δ Procainamide is the intravenous drug of choice for acute termination of suspected antidromic AVRT. If the tachycardia is definitely known to be antidromic AVRT, and it has been verified that the AV node (rather than a second accessory pathway) is acting as the retrograde limb of the circuit, one could consider treatment with an agent such as adenosine similar to therapy for orthodromic AVRT, but it is rare to have all of the necessary data in the acute setting to justify use of AV nodal blocking agents.

Graphic 62762 Version 7.0

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Medical therapy of arrhythmias associated with Wolff-Parkinson-White syndrome