Pre-excitation syndrome

Updated March 29, 2024

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of pre-excitation syndrome are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC 2020), the American Heart Association (AHA/HRS/ACC 2016), and the Heart Rhythm Society (HRS/PACES 2012).

Diagnostic investigations

Electrocardiography: as per ESC 2020 guidelines, consider obtaining noninvasive evaluation of the conducting properties of the accessory pathway in asymptomatic patients with pre-excitation.

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Diagnostic procedures

Electrophysiology study: as per ESC 2020 guidelines, conduct an electrophysiology study using isoprenaline to risk stratify asymptomatic patients with pre-excitation having high-risk occupations/hobbies, and those participating in competitive athletics.

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Therapeutic procedures

Catheter ablation: as per ESC 2020 guidelines, perform catheter ablation in asymptomatic patients if electrophysiology testing using isoprenaline identifies high-risk properties, such as:

shortest pre-excited RR interval during AF ≤ 250 ms

accessory pathway effective refractory period ≤ 250 ms

multiple accessory pathways

inducible accessory pathway-mediated tachycardia.

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Specific circumstances

Patients with pre-excited AF, pharmacologic management

As per ESC 2020 guidelines:

Consider administering IV formulations of the following medications for acute management of hemodynamically stable patients with pre-excited AF:

ibutilide

procainamide

flecainide

propafenone

Do not use IV amiodarone in patients with pre-excited AF.

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Follow-up and surveillance

Observation: as per ESC 2020 guidelines, consider obtaining clinical follow-up in asymptomatic patients with pre-excitation and a low-risk accessory pathway at invasive risk stratification.

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