A 35-year-old female presented with a history of palpitations and shortness of breath for the past 6 hours. She has a history of hypertension for the past 3 months and is on medication. On examination, her blood pressure was elevated and heart rate was rapid. An ECG showed Wolff-Parkinson-White syndrome. WPW is a condition where there is an extra pathway between the atria and ventricles that can cause rapid heart rates. Treatment options include medications, cardioversion, catheter ablation to destroy the extra pathway, or surgery.

1. CASE PRESENTATION
Dr. ADEEL AHMAD.
PGR WMW.

2. Name Sobia
Age 35 years
 Sex Female
Resident Faisal Abad
Presented
“Palpitation and SOB 6 hours”.
 Patient HTN+ 3 months (on regular medication) nonDM
presented in emergency with H/O palpitation that started
6hrs back. She complains of such a palpitation for last 3
months on and off, palpitation can occur any time that
have no relation to exercise or work load.She, along with
palpitation, also complains of SOB for up to a similiar
period. SOB can occur any time,no diurnal variation,no
seasonal history. There is no H/O orthopnea and PND.

3. Past History: Except HTN not significant
Personal History: Not significant
Family History: She is married and living a
happy life.
Treatment History:
She was on
Losartan 50 mg 1 po OD and
Tenormin 50 mg BD

4. Vitals
BP 170/100 mmHg
Pulse 120 beat/m
RR 20/M
Fever A/F

5. GPE
 Pallor -ve
 Cyanosis -ve
 Clubbing -ve
 Koilonychia -ve
 S /hemorrhage -ve
 Osler nodes absent
 Heberden nodes absent
 Boucard nodes absent
 Palmer erythema -ve
 Dupuytren contrature -ve
 Skin rash -ve
 Axillary nodes not palpable
 JVP not raised
 Thyroid normal
 Ankle edema absent
 Sign of dehyration -ve

6. CVS
On inspection; Shape of chest is normal.
On palpation; Apex beat in 5th intercostal space
just medial to mid clavicular line,no other sound is
palpable,no thrill,no murmur.
On auscultation; Both sound normal,no thrill,no
murmur.

7. Respiratory system
On inspection; Rate 20/m thoraco abdominal.
On palpation; Trachea is central,apex beat in 5th
medial to midclavicular line,chest movement and
expansion within normal range,no vocal fremitus.
On purcussion; upper border of liver is in 5th
intercostal space.
On auscultation; Breath sounds are normal,no
ronchi,no crepts.

8. GIT
On Inspection; Oral hygiene is good,
On Palpation; Not done
On Purcusion; Not done.
On Auscultation; B/S are audible,no bruit is
present.

9. CNS
HMF Normal.
Speech Normal
Cranial nerves Intact.
Motor Intact
Sensory Intact
Cerebellar Intact

13. Diagnostic criteria:
The QRS complex duration is >0.11 second; in
approximately 20% of individuals, the QRS complex
may not be >0.11 second.
PR is <0.12 second.
A delta wave is prominent, often in V3 through V6,
In type A WPW syndrome, a tall R wave present in V1
In type B WPW , the QRS complex is predominately
negative in V1 through V3 and upright in V5 and V6.

18. History
In 1930, Wolff, Parkinson and White described a
distinct (ECG) pattern in healthy young people with
short bursts of tachycardia.
In 1944, doctors confirmed the presence of extra
pathways

19. Prevalence:
WPW is a congenital heart abnormality
WPW occurs randomly in the general population
1 to 3 per 1,000 persons.
Men have a higher incidence of WPW than women.
Some cases of WPW are inherited.
7 to 20 percent of patients with WPW also have
congenital defects within the heart.

20. Symptoms of WPW
Any age, from infancy to adult years.
Heart palpitations
Racing feeling in your chest
Dizziness
Shortness of breath (dyspnea)
Anxiety
Rarely, cardiac arrest (sudden death)
Some people have WPW without any symptoms at all.

21. Types of WPW
Practical concept is that a negative delta wave usually
signals where the AP is:
A negative delta wave in a left-side, I and aVL
indicates a left-side AP.
A negative delta in a right-side lead such as V1 predicts
a right-side AP.
A negative delta in the inferior leads (II, III, and aVF)
indicates a posteroseptal AP.
A positive delta in the inferior leads predicts an
anteroseptal AP.
An isoelectric delta in V1 predicts an anteroseptal AP.

22. Left lateral wall - Negative delta waves in lead I
and aVL; positive or isoelectric in II, III, aVF and V1-4;
and negative or isoelectric delta waves in V5-6
Right free wall - Positive delta waves in I and II,
negative delta waves in aVR, isoelectric or negative
delta wave in aVF, isoelectric delta wave in V1,
isoelectric or positive delta waves in V2-3, and positive
delta waves in V4-6

23. Left posterior free wall - Positive delta waves in lead I
and aVL; negative delta waves in II, III, and aVF; positive
delta waves in V1-5; and negative or isoelectric delta wave
in V6
Posteroseptal - Positive delta waves in lead I and aVL
with negative delta waves in II, III, and aVF; isoelectric
waves in V1; and positive delta waves in the rest of the
precordial leads
Left anteroseptal - Positive delta waves in I, II, and
aVF; negative delta wave in aVR; isoelectric or positive
delta wave in V1; and positive delta waves in V2-6
Right anteroseptal - Positive delta waves in I, II, and
aVF; negative delta wave in aVR; negative or isoelectric
delta waves in V1-3; and positive delta waves in V4-6

24. Treatment
DD
AVNRT
Orthodromic AVRT
Antidromic AVRT

26. Narrow complex
Orthodromic AVRT and AVNRT blocking AV node
conduction
Vagal maneuvers (eg, Valsalva maneuver, carotid sinus
massage, splashing cold water or ice water on the face)
IV adenosine 6-12 mg via a large-bore
IV verapamil 5-10 mg or diltiazem 10 mg

27. Wide complex
Antidromic AVRT
Procainamide or
Amiodarone or
Flecainide if wide-complex tachycardia is present, if
patient hemodynamically stable
Ibutilide

28. Unstable patient
Synchronized electrical cardioversion,
A level of 100 J initially
If necessary, a second shock with higher energy (200 J
or 360 J)
Pregnancy Sotalol

29. Radiofrequency Ablation
Indication
Patients with symptomatic AVRT
Patients with AF
Patients with AVRT or AF with rapid ventricular rates
found incidentally during EPS,RR interval during AF
<250 ms
Asymptomatic patients who would endanger the
public safety
Patients with WPW and a family history of sudden
cardiac death

30. RFA
In RF ablation, platinum-tipped 3.5- to 8-mm
steerable multielectrode catheters are advanced via the
femoral artery or vein to locate and ablate the AP by
delivering thermal RF energy

31. Surgical treatment
Surgical treatment is replaced by RFA
Patients in whom RF catheter ablation (with repeated
attempts) fails
Patients undergoing concomitant cardiac surgery

32. Long-term antiarrhythmic therapy
Oral medication is the mainstay of therapy in patients
not undergoing RFA. Choices include the following:
Dual-drug therapy (eg, procainamide and verapamil
[class Ia and IV])
Class Ic drugs (eg, flecainide, propafenone), typically
used with an AV nodal blocking agent
Class III drugs (eg, amiodarone, sotalol)
In pregnancy, sotalol (class B) or flecainide (class C)

33. WHAT IS DIAGNOSIS

34. WHAT IS DIAGNOSIS

36. WHAT IS DIAGNOSIS

38. THANKS