You see a 26 year old lady who has presented concerned that her lap band may have slipped. She had one vomit post eating last night and then woke with palpitations at 4am with associated shortness of breath and feeling faint.

On examination her observations are RR16 Sats 96% HR85 BP140/75 and she is afebrile. There is nil to find on cardio-respiratory or neurological exam. She is mildly tender in the epigastrium.

ECG is as follows:

Interpretation:

• Rate: 78
• Rhythm: NSR
• Axis: Normal
• Morphology:
  • • Delta wave – positive
    • RBBB
    • Inferior and septal ST depression, also persists in V4/5
    • Biphasic T waves V2/3
• Intervals:
  • • PR 100
    • QRS 160
• Summary: Pre-excitation pattern consistent with WPW Type A – consistent with Left Posterior septal re-entry pathway.

Wolf Parkinson White Syndrome:

• Type A: +ve delta waves in all precordial leads with R/S >1 in V1 = Left atrioventricular connections
• Type B: -ve delta waves in leads V1 and V2 = Right AV connections
• Concealed Pathway: a retrograde only accessory pathway (therefore all anterograde conduction occurs via the AVN and cannot see WPW in SR)

Management:

• Bloods: FBC, U+Es, Mg, TFTs unremarkable
• CXR: normal cardiac contours
• Telemetry under Cardiology team
• NOT for medications to affect normal conduction pathway (ie Adenosine, Amiodarone, B blockers, CCBs contra-indicated) In the event of tachydysrrhythmia or instability (eg hypotension, altered GCS) consider DCCV.

Clinical Closure:

• On further questioning she had intermittently been experiencing palpitations for 3 months and had had one episode of syncope whilst pregnant 2 years before.
• She was admitted under the Cardiology team
• Echo showed abnormal early systolic motion of the basal inferiorlateral wall consistent with WPW.
• She was started on Flecainide 100mg BD and Verapamil SR 180mg OD and discharged home with outpatient Electrophysiology Studies (currently pending)
• Ablation may be an option for ultimate management.