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Perm J. 2010 Summer; 14(2): 53.
Published online Summer 2010.
PMCID: PMC2912082

ECG Diagnosis: Wolff-Parkinson-White Syndrome

Joel T Levis, MD, FACEP, FAAEM

Wolff-Parkinson-White Syndrome (WPWS) is defined as the presence of an accessory pathway (AP) and has a predisposition to the development of supraventricular tachydysrhythmias. Conduction over an AP circumvents conduction delay occurring within the atrioventricular node (AVN), which leads to early eccentric activation of the ventricles and fusion complexes.1 If WPWS with atrial fibrillation (AF) is treated by drugs that prolong the AVN refractory period (eg, calcium-channel blockers, beta-blockers, digoxin, adenosine), the rate of conduction through the AP may increase and degenerate to ventricular fibrillation (VF).2 Unstable patients with WPWS and AF should receive immediate electrical cardioversion.3 Stable patients can be chemically cardioverted with IV procainamide. Amiodarone should be used with caution due to its ability to cause ventricular rate acceleration and degeneration into VF.3 Ibutilide is considered an alternative agent, although it has numerous side effects.1 Cardiology or electro-physiology consultation with consideration for radiofrequency mapping and ablation should occur for patients presenting with AF in the setting of WPWS.

Figure 1
12-lead ECG in a man, age 33 years, with palpitations, chest discomfort, and shortness of breath
Figure 2
12-lead ECG from same patient two days earlier


  • Levis JT, Garmel GM. Atrial fibrillation with Wolff-Parkinson-White syndrome. Internet J Emerg Med [serial on the Internet]. 2009. [cited 2010 Mar 8];5(1) [about 1 p]. Available from:
  • Garmel GM. Wide complex tachycardias: understanding this complex condition: Part 1—epidemiology and electrophysiology. West J Emerg Med. 2008 Jan;9(1):28–39. [PMC free article] [PubMed]
  • Fengler BT, Brady WJ, Plautz CU. Atrial fibrillation in the Wolff-Parkinson-White syndrome: ECG recognition and treatment in the ED. Am J Emerg Med. 2007 Jun;25(5):576–83. [PubMed]

Articles from The Permanente Journal are provided here courtesy of Kaiser Permanente