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32 yo fem presenting as an outpatient to the clinic for a repeat ECG. She was found to have this abnormal ECG upon her arrival to the ED 2 days prior where pt c/o dizziness.


So far, you are right on all counts. What is the diagnosis?

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I called this wpw type B but because of the dominant S wave in v1 and v2 but the cardiologist called it type A and I have yet to ask him why. I will follow and let you know. As far as treatment, I believe an ICD is in order. Patient is symptomatic and at high risk for SCD. Other than that, any pharm treatment indicated for this young lady?

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No problem; cases are a chance for all of us to learn.


Dizzy suggests maybe an episode of paroxsymal SVT. I'd probably do a Holter monitor to see what the rhythm is at times like that. Would consider a trial of diltiazem before amiodarone given the possible complications of amiodarone use, especially on a patient so young.



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Thanks for the help guys. I assumed ICD was the first course. Would it be indicated with syncope? What if the holter shows asymptomatic psvt or pvt? Just the CCB or do you consider ablation? Would you worry about runs of tachycardia becoming symptomatic at some point?

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An ICD wouldn't be the first course, especially in one so young and presumably without significant cardiomyopathy.


The Holter monitor -- or an event recorder -- would let us understand what the rhythm was that caused the syncope. It could have been anything from a long sinus pause, to PSVT, to PAF with RVR, or even something unrelated to WPW, like a long run of NSVT. I would definitely get an echocardiogram ASAP to rule out cardiomyopathy, especially hypertrophic obstructive cardiomyopathy. HOCM, in the context of dehydration, can cause syncope.


Until the event can be captured and understood better, I would be loath to recommend surgery, including an ablation. Trying a CCB seems like a reasonablly conservative approach at start. An EP study, with a possible ablation, may very well be in the cards later.


Hope this helps. This is only me talking and others might try something else. A 32-year-old woman has a lot of living to do yet and I'd want to avoid rocking her world any more than is necessary.

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  • 2 weeks later...

So i spoke with another cardiologist regarding the original ECG and he concurred that it was, indeed, type B but added that typing WPW is obsolete. He pointed me to the following algorithm for determining location of an accessory pathway:




Following the algorithm gives me accessory pathway locacted in the right anteroseptal wall due to isoelectric delta in aVL and LBBB pattern.

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