A 22-year-old man comes to the office for evaluation of an abnormal ECG. The patient was seen recently at an urgent care clinic for chest pain and was diagnosed with costochondritis. The chest pain subsequently resolved with ibuprofen. He has no prior history of chest pain, palpitations, or lightheadedness. However, he had an abnormal ECG finding on that visit and was advised to follow-up with a primary care physician. The patient does not use tobacco, alcohol, or illicit drugs. He has no family history of heart disease or arrhythmia.
His blood pressure is 118/78 mm Hg and pulse is 88/min. Cardiopulmonary, abdominal, and neurological examination findings are unremarkable.
Resting ECG performed in the primary care office is shown here. The ECG from the urgent care clinic also has similar findings.
Which of the following is the best next step in management of this patient?

Question

A 22-year-old man comes to the office for evaluation of an abnormal ECG.  The patient was seen recently at an urgent care clinic for chest pain and was diagnosed with costochondritis.  The chest pain subsequently resolved with ibuprofen.  He has no prior history of chest pain, palpitations, or lightheadedness.  However, he had an abnormal ECG finding on that visit and was advised to follow-up with a primary care physician.  The patient does not use tobacco, alcohol, or illicit drugs.  He has no family history of heart disease or arrhythmia.
His blood pressure is 118/78 mm Hg and pulse is 88/min.  Cardiopulmonary, abdominal, and neurological examination findings are unremarkable.
Resting ECG performed in the primary care office is shown here.  The ECG from the urgent care clinic also has similar findings.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

The ECG findings of a short PR interval (<0.12 seconds) and slurred upstroke of the QRS complex (delta wave) are typical of Wolff-Parkinson-White (WPW) pattern due to an atrioventricular (AV) accessory pathway. Most patients are asymptomatic, and this abnormality is often detected on a routine evaluation done for other reasons. However, patients are at increased risk for arrhythmias such as atrial fibrillation (AF) and AV reentrant tachycardia (AVRT). AF with rapid ventricular response can degenerate into ventricular fibrillation and cause sudden cardiac death (SCD). ECG Patients at highest risk for arrhythmias include those with a history of AF or AVRT and with a short refractory period (<250 msec) of the accessory pathway. Risk stratification of asymptomatic patients can be performed with noninvasive tests (eg, exercise testing or procainamide challenge) and/or electrophysiologic study (EPS) to identify those at greatest risk for SCD. Intermittent loss of preexcitation (ie, loss of delta waves on ECG) during faster heart rates with exercise or procainamide challenge suggests a longer refractory period that will not be able to conduct often enough during AF to degenerate into VF. These low-risk patients can be managed conservatively without further evaluation or treatment. (Choices A and B) Amiodarone and/or AV nodal blocking agents (beta blockers, calcium channel blockers, adenosine, digoxin) can result in preferential conduction of impulses via the accessory pathway and cause VF in patients with AF and underlying WPW pattern. (Choice C) Electrophysiologic testing with a catheter ablation procedure is indicated in selected symptomatic patients with cardiac arrhythmias (AVRT, preexcited AF or flutter) and asymptomatic patients with high risk occupations (eg, airline pilots, truck drivers, athletes). (Choice E) An implantable defibrillator is not indicated in patients with WPW pattern. Educational objective: Risk stratification of asymptomatic patients with WPW pattern on ECG can be performed with noninvasive tests (eg, exercise testing or procainamide challenge) and/or electrophysiologic study (EPS) to identify those at greatest risk of sudden cardiac death. Low-risk patients with intermittent loss of preexcitation during faster heart rates can be managed conservatively without further evaluation or treatment. __________ References: Noninvasive risk stratification for sudden death in asymptomatic patients with Wolff-Parkinson-White syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/25662922)

A 22-Year-Old Man Comes to the Office for Evaluation of an Abnormal