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cardio.wpw.chronic.v1PRODUCTION
cardio.wpw.chronic.v1

Wolff-Parkinson-White / ventricular preexcitation (chronic ablation pathway)

cardiologychronicadultpediatric
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm preexcitation; classify symptomatic WPW vs asymptomatic preexcitation

Inputs
2
Actions
0
Advance rule
Set
Advance when

preexcitation + symptom status framed

Patient inputs (11)

Pediatric vs adult; risk + ablation considerations

Detect AV-nodal blockers risky in preexcited AF

Symptomatic WPW = ablation Class I; asymptomatic = risk-stratify

Confirms manifest preexcitation (vs concealed pathway)

Preexcited AF = SCD-risk marker + AV-nodal-blocker contraindication

Antiarrhythmic dosing if pharmacologic path

Abrupt loss of preexcitation on exercise = low-risk pathway

PRKAG2/Danon/Fabry familial preexcitation — cardiomyopathy evaluation

Defer ablation if feasible; class IC if needed; avoid AV-nodal blockers in preexcited AF

EP study SPERRI/APERP ≤250 ms = high-risk pathway

High-risk occupation/competitive athlete lowers threshold for EP+ablation

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Severity triggers (9)

9 need judgement
  • informationallife_threateningpreexcited_af_avoid_av_nodal_blockers
    Preexcited AF (irregular wide-complex) — AV-nodal blockers (digoxin/verapamil/diltiazem/IV BB/adenosine) CONTRAINDICATED (→ VF); urgent ablation; acute unstable → synchronized cardioversion — 2019 ESC SVT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresymptomatic_wpw_ablation
    Symptomatic WPW (AVRT or preexcited AF) — catheter ablation Class I (curative) — 2015 ACC/AHA/HRS SVT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehigh_risk_asymptomatic_branch
    Asymptomatic preexcitation with SPERRI/APERP ≤250 ms, multiple pathways, or inducible preexcited AF — high-risk → ablation — 2019 ESC SVT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_special_pop
    Pregnancy with WPW — defer ablation if feasible; AVOID AV-nodal blockers in preexcited AF; class IC if drug needed; cardio-obstetric — ESC 2018 Pregnancy; 2019 ESC SVT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateoccupation_athlete_branch
    High-risk occupation (pilot, driver) or competitive athlete with preexcitation — lower threshold for EP study + ablation — 2019 ESC SVT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefamilial_genetic_branch
    Familial preexcitation (PRKAG2 glycogen storage, Danon, Fabry) — evaluate for associated cardiomyopathy + genetics + cascade — 2019 ESC SVT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateablation_declined_pharmacologic
    Symptomatic AVRT, ablation declined/not feasible — class IC (flecainide/propafenone) if no structural heart disease — 2015 ACC/AHA/HRS SVT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_special_pop
    CKD — class IC/antiarrhythmic renal dose-gating if pharmacologic path — KDIGO 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildlow_risk_asymptomatic_branch
    Asymptomatic preexcitation with abrupt loss of preexcitation on exercise (low-risk pathway) — reassurance + shared-decision surveillance — 2019 ESC SVT
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

WPW ablation pathway + safe pharmacologic alternative (2015 ACC/AHA/HRS SVT; 2019 ESC SVT)
axis: wpw_ablation_pathwaystep 1 - Step 1 — Risk-stratify; preexcited-AF safety (AV-nodal-blocker avoidance)
Selected step "Step 1 — Risk-stratify; preexcited-AF safety (AV-nodal-blocker avoidance)" — Any preexcitation
  • AVOID AV-nodal blockers (digoxin, verapamil, diltiazem, IV beta-blockers, adenosine) in preexcited AF
    first line
    deprescribe
    triggers: preexcited_AF_or_at_risk
    AV-nodal blockade in preexcited AF accelerates accessory-pathway conduction → VF — absolute avoidance (2019 ESC SVT)

outpatient playbook — drug actions (2)

  1. 1. accessory-pathway ablation referral
    procedure • catheter • n/a
    trigger: Symptomatic WPW / high-risk asymptomatic (2015 ACC/AHA/HRS SVT)
    Curative first-line
  2. 2. class IC if ablation declined
    flecainide 50–100 mg BID / propafenone 150 mg TID • PO • BID/TID
    trigger: AVRT, ablation declined, no SHD (2015 ACC/AHA/HRS SVT)
    AVRT prevention alternative

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ECG ventricular preexcitation (delta wave, short PR); Recurrent regular palpitations / documented AVRT; Preexcited atrial fibrillation (irregular wide-complex tachycardia).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Wolff-Parkinson-White / ventricular preexcitation (chronic ablation pathway)** (cardio.wpw.chronic.v1).
Phenotype framing: Manifest WPW vs concealed pathway vs other SVT vs preexcitation phenocopy (PRKAG2/Danon/Fabry)
Scope: Confirm preexcitation; classify symptomatic WPW vs asymptomatic preexcitation

No severity triggers fired against current inputs.

Plan

Regimen axis: **WPW ablation pathway + safe pharmacologic alternative (2015 ACC/AHA/HRS SVT; 2019 ESC SVT)** — step "Step 1 — Risk-stratify; preexcited-AF safety (AV-nodal-blocker avoidance)".
1. AVOID AV-nodal blockers (digoxin, verapamil, diltiazem, IV beta-blockers, adenosine) in preexcited AF (deprescribe, first line) — AV-nodal blockade in preexcited AF accelerates accessory-pathway conduction → VF — absolute avoidance (2019 ESC SVT)

Setting playbook (outpatient) — Risk-stratify preexcitation, ablate symptomatic/high-risk, enforce AV-nodal-blocker avoidance in preexcited AF, evaluate familial forms (2015 ACC/AHA/HRS SVT; 2019 ESC SVT)
2. accessory-pathway ablation referral procedure catheter n/a — Symptomatic WPW / high-risk asymptomatic (2015 ACC/AHA/HRS SVT) (Curative first-line)
3. class IC if ablation declined flecainide 50–100 mg BID / propafenone 150 mg TID PO BID/TID — AVRT, ablation declined, no SHD (2015 ACC/AHA/HRS SVT) (AVRT prevention alternative)

Non-pharmacologic actions:
- EP referral for ablation — 2015 ACC/AHA/HRS SVT
- Enforce AV-nodal-blocker avoidance in preexcited AF — 2019 ESC SVT
- Genetic/cardiomyopathy evaluation if PRKAG2/Danon/Fabry familial preexcitation — 2019 ESC SVT

AVOID / contraindication checks:
- AV nodal blockers CONTRAINDICATED in preexcited AF digoxin verapamil diltiazem IV BB adenosine — 2019 ESC SVT
- Catheter ablation is curative first line for symptomatic WPW — 2015 ACC/AHA/HRS SVT
- Class IC only if no structural heart disease — 2015 ACC/AHA/HRS SVT
- Risk stratify asymptomatic preexcitation before reassurance — 2019 ESC SVT

Monitoring

Regimen monitoring:
- post ablation ECG for recurrent preexcitation — 2015 ACC/AHA/HRS SVT
- symptom surveillance AVRT recurrence — 2019 ESC SVT
- medication reconciliation no AV nodal blockers if preexcited AF risk — 2019 ESC SVT
- genetic cardiomyopathy surveillance if PRKAG2 Danon Fabry — 2019 ESC SVT

Setting (outpatient) monitoring:
- Post-ablation ECG + symptom surveillance — 2015 ACC/AHA/HRS SVT

Follow-up plan: Genetic/cardiomyopathy evaluation if familial; reassurance for resolved/low-risk
- Close-out criterion: follow-up + genetic plan documented

Monitoring phase: Post-ablation recurrence surveillance; symptom + ECG follow-up

Disposition

Current setting: outpatient — Risk-stratify preexcitation, ablate symptomatic/high-risk, enforce AV-nodal-blocker avoidance in preexcited AF, evaluate familial forms (2015 ACC/AHA/HRS SVT; 2019 ESC SVT)

Disposition criteria:
- Symptomatic / high-risk → ablation
- Asymptomatic low-risk (exercise preexcitation loss) → reassurance + shared-decision
- Familial preexcitation → genetic + cardiomyopathy pathway

Escalation triggers (move to higher acuity):
- Preexcited AF / syncope / aborted SCD → urgent ablation; acute episode → ED (no AV-nodal blockers) — 2019 ESC SVT
- Recurrent preexcitation post-ablation → repeat EP/ablation — 2015 ACC/AHA/HRS SVT

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Preexcited AF (irregular wide-complex) — AV-nodal blockers (digoxin/verapamil/diltiazem/IV BB/adenosine) CONTRAINDICATED (→ VF); urgent ablation; acute unstable → synchronized cardioversion — 2019 ESC SVT
- [SEVERE] Symptomatic WPW (AVRT or preexcited AF) — catheter ablation Class I (curative) — 2015 ACC/AHA/HRS SVT
- [SEVERE] Asymptomatic preexcitation with SPERRI/APERP ≤250 ms, multiple pathways, or inducible preexcited AF — high-risk → ablation — 2019 ESC SVT

Citations

- 2015 ACC/AHA/HRS SVT Guideline + 2019 ESC SVT Guideline; 2017 AHA/ACC/HRS + 2022 ESC VA (SCD context) [PMID:26399663](https://pubmed.ncbi.nlm.nih.gov/26399663/)
- Cited evidence (PMID 31504425) [PMID:31504425](https://pubmed.ncbi.nlm.nih.gov/31504425/)
- Cited evidence (PMID 29084731) [PMID:29084731](https://pubmed.ncbi.nlm.nih.gov/29084731/)
- Cited evidence (PMID 36017572) [PMID:36017572](https://pubmed.ncbi.nlm.nih.gov/36017572/)

Last reconciled with current guidelines: 2026-05-16.
References
  • 2015 ACC/AHA/HRS SVT Guideline + 2019 ESC SVT Guideline; 2017 AHA/ACC/HRS + 2022 ESC VA (SCD context) — PMID:26399663
  • Cited evidence (PMID 31504425) — PMID:31504425
  • Cited evidence (PMID 29084731) — PMID:29084731
  • Cited evidence (PMID 36017572) — PMID:36017572