Revista de Medicina Desportiva (English) March 2018 - Page 12

Revista Medicina Desportiva informa, 2018; 9(2):10-11. Cyclist with Wolff-Parkinson- White Pattern – Risk Stratification and Therapeutic Approach Dra. Telma Miragaia 1 , Dra. Carina Machado 2 , Dr. Rui Candeias 3 , Dr. Hélder Dores 4 General Health Practitioner Specialist, Health Unity in the Island of S. Miguel, Azores; 2 Cardiology Specialist at the Hospital do Divino Espírito Santo, Ponta Delgada, Azores; 3Graduated Cardiology Specialist at the Centro Hospitalar Universitário do Algarve; 4 Cardiology Specialist at the Hospital das Forças Armadas and Hospital da Luz – Lisbon. ABSTRACT The sports medical examination is essential for the screening of alterations that may predispose the occurrence of serious clinical events, including sudden death. The pattern of ventricular preexcitation Wolf-Parkinson-White (WPW) is considered a pathological alteration in the athlete’s electrocardiogram (ECG), and a risk stratification is subsequently recommended. We present the case of a 23-year-old cyclist who was submitted to an ECG for the first time in the context of a sports medical examination and who revealed WPW pattern. The following complementary evaluation included a transthoracic echocardiogram, a fatigue test and a 24 hour Holter; the medical decision was to proceed with a radiofre- quency ablation of the accessory pathway, which underwent without complications and was successful. KEYWORDS Athlete, Wolf-Parkinson-White, Risk Stratification. Introduction Regular exercise is associated with multiple health benefits, but it is not risk-free and can trigger serious clinical events, including sudden death in individuals at increased risk. 1 Pre-competitive assessment is essential in identifying athletes with pathologies that may aggravate during exercise or increase the risk of complications during exercise. The 12-lead resting electrocardio- gram (ECG) is an indispensable test in cardiac evaluation, allowing early detection of several pathologies associated with an increased risk of sudden death in athletes. 2 The interpretation of the athlete’s ECG is controversial, however, mainly due to the high rate of false positives. In this context, increasingly restric- tive criteria has been published in recent years, reflecting a significant reduction in false-positive cases. In the most recent international criteria for ECG interpretation in athletes (Figure 1), ventricular pre-excitation, defined by the presence of a PR interval <120ms, delta wave and QRS> 120ms, remains a consider- able pathological alteration requiring further investigation. 3 10 march 2018 www.revdesportiva.pt The annual risk of sudden death in patients with Wolff-Parkinson-White (WPW) is estimated to be 0.02-0.05%, accounting for 2-4% of sudden deaths in the general population. The underlying mechanism is ventricular fibrillation, triggered by rapid pulses of atrial fibrillation (300-500 cycles per minute) through the accessory pathway. 4 In this manner, the risk stratification of individuals with WPW is essential. The performance of the exercise tolerance test in order to assess whether the pre-excitation pattern arises or is maintained during exertion, is a crucial aspect, especially in athletes. If high risk is considered, radiofrequency ablation should be performed, an intervention considered to be safe and increas- ingly effective. 5 Clinical case Female athlete, Caucasian, 23 years old, mountain biking practitioner who undergoes a pre-participation physical examination for the first time in order to start practicing a federated sport. No complaints were presented along with denying any significant personal or relevant fam- ily history. The resting ECG (Figure 2) showed a sinus rhythm with 79 beats per min- ute, a short PQ interval (99ms), a delta wave in all leads and a broad QRS. The subsequent follow-up evalua- tion included: • Transthoracic echocardiogram: no relevant changes (presence of physiological adaptations induced by physical exercise); • 24-hour Holter monitoring: sinus rhythm with an average heart rate of 85 (53-137) bpm; WPW pat- tern throughout the recording; no supraventricular extrasystoles and Figure 1 – International consensus standards for ECG interpretation in athletes. AV, atrioventricular; LBBB, left bundle branch block; LVH, left ventricular hypertrophy; PVC, premature ventricular contraction; RBBB, right bundle branch block; RVH, right ventricular hypertrophy; SCD, sudden cardiac death. http://bjsm.bmj.com/con- tent/51/9/704.