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A Patient With Palpitations—Exceptions Prove the Rule

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1 Credit CME

A patient in their 40s presented with complaints of intermittent episodes of palpitations for the past year. The patient described the palpitations as sudden in onset, persisting for 2 to 3 minutes, and terminating spontaneously and abruptly. The frequency of these palpitation episodes varied from once per week to less than once per month. There were no associated syncopal episodes or giddiness. All the episodes terminated before the patient could reach the hospital. There was no other contributory history. At presentation, the patient was in sinus rhythm with pulse rate of 100 beats/min, blood pressure of 126/80 mm Hg, and a normal cardiovascular examination. The 12-lead electrocardiogram (ECG) is shown in the Figure.

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Various algorithms have been established for localizing the accessory pathways based on the surface ECG. The most widely studied and well-established Arruda algorithm1 suggested the presence of a posteroseptal accessory pathway in this patient.

Risk stratification of accessory pathways depends on the identification of markers for sudden cardiac death. These include smaller APERP (less than 250 milliseconds), shortest preexcited R-R intervals of less than 250 milliseconds during atrial fibrillation, presence of multiple accessory pathways, Ebstein anomaly, and familial Wolff-Parkinson-White (WPW) syndrome. On the other hand, abrupt loss of preexcitation during treadmill testing and intermittent preexcitation on the surface ECG imply the presence of bypass tracts with longer refractory periods.2 The coronary sinus pathway is associated with coronary sinus aneurysm, which is found to have a rapid conduction time and thereby high risk of fast ventricular rate and sudden cardiac death during atrial fibrillation episodes.3

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Ramanathan Velayutham, MD, Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research JIPMER Campus Rd, Dhanvantari Nagar, Puducherry – 605006, India (nadalram@gmail.com).

Published Online: September 19, 2022. doi:10.1001/jamainternmed.2022.3813

Conflict of Interest Disclosures: None reported.

References
1.
Arruda  MS , McClelland  JH , Wang  X ,  et al.  Development and validation of an ECG algorithm for identifying accessory pathway ablation site in Wolff-Parkinson-White syndrome.   J Cardiovasc Electrophysiol. 1998;9(1):2-12. doi:10.1111/j.1540-8167.1998.tb00861.xPubMedGoogle ScholarCrossref
2.
Page  RL , Joglar  JA , Caldwell  MA ,  et al; Evidence Review Committee Chair‡.  2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society  [published correction appears in Circulation. 2016 Sep 13;134(11):e232-3].  Circulation. 2016;133(14):e471-e505. doi:10.1161/CIR.0000000000000310PubMedGoogle ScholarCrossref
3.
Al Fagih  A , Al Zahrani  G , Al Hebaishi  Y , Dagriri  K , Al Ghamdi  SA .  Coronary sinus diverticulum as a cause of resistant posteroseptal pathway ablation.   J Saudi Heart Assoc. 2011;23(1):41-44. doi:10.1016/j.jsha.2010.07.009PubMedGoogle ScholarCrossref
4.
Klein  GJ , Gulamhusein  SS .  Intermittent preexcitation in the Wolff-Parkinson-White syndrome.   Am J Cardiol. 1983;52(3):292-296. doi:10.1016/0002-9149(83)90125-XPubMedGoogle ScholarCrossref
5.
Mah  DY , Sherwin  ED , Alexander  ME ,  et al.  The electrophysiological characteristics of accessory pathways in pediatric patients with intermittent preexcitation.   Pacing Clin Electrophysiol. 2013;36(9):1117-1122. doi:10.1111/pace.12144PubMedGoogle ScholarCrossref
6.
Orczykowski  M , Walczak  F , Derejko  P ,  et al.  Ventricular fibrillation risk factors in over one thousand patients with accessory pathways.   Int J Cardiol. 2013;167(2):525-530. doi:10.1016/j.ijcard.2012.01.076PubMedGoogle ScholarCrossref
7.
Kiger  ME , McCanta  AC , Tong  S , Schaffer  M , Runciman  M , Collins  KK .  Intermittent versus persistent Wolff-Parkinson-White syndrome in children: electrophysiologic properties and clinical outcomes.   Pacing Clin Electrophysiol. 2016;39(1):14-20. doi:10.1111/pace.12732PubMedGoogle ScholarCrossref
8.
Aleong  RG , Singh  SM , Levinson  JR , Milan  DJ .  Catecholamine challenge unmasking high-risk features in the Wolff-Parkinson-White syndrome.   Europace. 2009;11(10):1396-1398. doi:10.1093/europace/eup211PubMedGoogle ScholarCrossref
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