How should I manage a patient with WPW who presents with atrial fibrillation?

In managing a patient with Wolff-Parkinson-White (WPW) syndrome who presents with atrial fibrillation (AF), urgent specialist cardiology referral is essential due to the risk of rapid ventricular rates via the accessory pathway, which can precipitate ventricular fibrillation and sudden death ¹. Rate-control drugs such as beta-blockers and calcium-channel blockers are contraindicated because they may facilitate conduction through the accessory pathway, worsening ventricular response ¹. Instead, management should focus on urgent electrical cardioversion if the patient is haemodynamically unstable or if rapid ventricular rates are not controlled ¹.

For haemodynamically stable patients, antiarrhythmic drugs that block conduction through the accessory pathway, such as intravenous procainamide, may be used under specialist supervision to control the arrhythmia ¹. Amiodarone may be considered cautiously but is generally reserved for specialist use due to its complex pharmacology and delayed onset ¹. The use of other antiarrhythmics requires specialist input given the risk of proarrhythmia and drug interactions ¹.

Following acute management, definitive treatment with catheter ablation of the accessory pathway is recommended to prevent recurrence and reduce the risk of sudden cardiac death ¹. This aligns with expert opinion emphasizing the importance of specialist interventions such as catheter ablation in WPW with AF ¹.

In summary, the key management steps are: avoid AV nodal blocking agents, consider urgent electrical cardioversion if unstable, use specialist-guided antiarrhythmics like procainamide if stable, and arrange prompt cardiology referral for consideration of catheter ablation ¹. Recent literature on rapid AF management in emergency settings supports the urgency of controlling ventricular rate and rhythm to prevent deterioration, reinforcing the guideline recommendations (Alsagaff et al., 2022).