Author + information
- Published online April 5, 2016.
- Sana M. Al-Khatib, MD, MHS, FACC, FAHA, Chair, Evidence Review Committee,
- Aysha Arshad, MD, FACC, FHRS, Evidence Review Committee Member∗,
- Ethan M. Balk, MD, MPH, Evidence Review Committee Member∗,
- Sandeep R. Das, MD, MPH, FACC, FAHA, Evidence Review Committee Member∗,
- Jonathan C. Hsu, MD, MAS, FACC, FHRS, Evidence Review Committee Member∗,
- José A. Joglar, MD, FACC, FAHA, FHRS, SVT Guideline Vice Chair, Evidence Review Committee Member and
- Richard L. Page, MD, FACC, FAHA, FHRS, SVT Guideline Chair, Evidence Review Committee Member
Objective To review the literature systematically to determine whether noninvasive or invasive risk stratification, such as with an electrophysiological study of patients with asymptomatic pre-excitation, reduces the risk of arrhythmic events and improves patient outcomes.
Methods PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (all January 1, 1970, through August 31, 2014) were searched for randomized controlled trials and cohort studies examining noninvasive or invasive risk stratification in patients with asymptomatic pre-excitation. Studies were rejected for low-quality design or the lack of an outcome, population, intervention, or comparator of interest or if they were written in a language other than English.
Results Of 778 citations found, 9 studies met all the eligibility criteria and were included in this paper. Of the 9 studies, 1 had a dual design—a randomized controlled trial of ablation versus no ablation in 76 patients and an uncontrolled prospective cohort of 148 additional patients—and 8 were uncontrolled prospective cohort studies (n=1,594). In studies reporting a mean age, the range was 32 to 50 years, and in studies reporting a median age, the range was 19 to 36 years. The majority of patients were male (range, 50% to 74%), and <10% had structural heart disease. In the randomized controlled trial component of the dual-design study, the 5-year Kaplan-Meier estimates of the incidence of arrhythmic events were 7% among patients who underwent ablation and 77% among patients who did not undergo ablation (relative risk reduction: 0.08; 95% confidence interval: 0.02 to 0.33; p<0.001). In the observational cohorts of asymptomatic patients who did not undergo catheter ablation (n=883, with follow-up ranging from 8 to 96 months), regular supraventricular tachycardia or benign atrial fibrillation (shortest RR interval >250 ms) developed in 0% to 16%, malignant atrial fibrillation (shortest RR interval ≤250 ms) in 0% to 9%, and ventricular fibrillation in 0% to 2%, most of whom were children in the last case.
Conclusions The existing evidence suggests risk stratification with an electrophysiological study of patients with asymptomatic pre-excitation may be beneficial, along with consideration of accessory-pathway ablation in those deemed to be at high risk of future arrhythmias. Given the limitations of the existing data, well-designed and well-conducted studies are needed.
- ACC/AHA Evidence Review Committee
- ACC/AHA Clinical Practice Guideline
- accessory atrioventricular bundle
- cardiac arrhythmias
- pre-excitation syndromes
- risk assessment
- sudden cardiac death
- Wolff–Parkinson-White Syndrome
↵∗ These members of the Evidence Review Committee are listed alphabetically, and all participated equally in the process.
This document was approved by the American College of Cardiology Board of Trustees and Executive Committee, the American Heart Association Science Advisory and Coordinating Committee, and the Heart Rhythm Society Board of Trustees in August 2015, and by the American Heart Association Executive Committee in September 2015.
The American College of Cardiology requests that this document be cited as follows: Al-Khatib SM, Arshad A, Balk EM, Das SR, Hsu JC, Joglar JA, Page RL. Risk stratification for arrhythmic events in patients with asymptomatic pre-excitation: a systematic review for the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2016;67:1624–38.
This article has been copublished in Circulation and HeartRhythm Journal.
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- 2016 American College of Cardiology Foundation, the American Heart Association, Inc., and the Heart Rhythm Society
- ACC/AHA Task Force Members
- Table of Contents
- Presidents and Staff
- Appendix 1 Author Relationships With Industry and Other Entities (Relevant)∗—Risk Stratification for Arrhythmic Events in Patients With Asymptomatic Pre-Excitation: A Systematic Review for the 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia (May 2014)