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.