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6.2 Management of Asymptomatic Pre-Excitation 6.2.1 PICOTS Critical Questions See the ERC systematic review report, “Risk Stratification for Arrhythmic Events in Patients With Asymptomatic Pre- Excitation” for the complete evidence review on the management of asymptomatic pre-excitation,9 and see Online Data Supplements 13, 14, and 15 for additional data on asymptomatic pre-excitation, which were reproduced directly from the ERC’s systematic review. These recommendations have been designated with the notation SR to emphasize the rigor of support from the ERC’s systematic review. PICOTS Question 1 did not provide adequate data for a recommendation; the other 3 PICOTS questions are addressed in the recommendations in Section 6.2.2. As noted in Section 1.1, the recommendations in Section 6.3 are based on a separately commissioned systematic review of the available evidence, the results of which were used to frame our decision making. Full details are provided in the ERC’s systematic review report.9 The following 4 questions were considered by the ERC: 1 What is the comparative predictive accuracy of inva- sive EP study (without catheter ablation of the accessory pathway) versus noninvasive testing for predicting arrhythmic events (including SCD) in patients with asymptomatic pre-excitation? 2. What is the usefulness of invasive EP study (without catheter ablation of the accessory pathway) versus no testing for predicting arrhythmic events (including SCD) in patients with asymptomatic pre-excitation? 3. What is the usefulness of invasive EP study (without catheter ablation of the accessory pathway) or noninvasive EP study for predicting arrhythmic events (including SCD) in patients with asymptomatic pre-excitation? 4. What are the efficacy and effectiveness of invasive EP study with catheter ablation of the accessory pathway as appropriate versus noninvasive tests with treatment (including observation) or no testing/ablation as appropriate for preventing arrhythmic events (including SCD) and improving outcomes in patients with asymptomatic pre-excitation? Figure 11. Ongoing management of focal atrial tachycardia. Colors correspond to Class of Recommendation in Table 1; drugs listed alphabetically. Pt indicates patient; and SHD, structural heart disease (including ischemic heart disease). IIb C-LD 3. Oral beta blockers, diltiazem, or verapamil may be reasonable for ongoing management of orthodromic AVRT in patients with preexcitation on their resting ECG who are not candidates for, or prefer not to undergo, catheter ablation.46,287 See Online Data Supplements 11 and 12. One RCT supports the use of verapamil for prevention of orthodromic AVRT in patients with pre-excitation on their resting ECG (manifest accessory pathway).46 There are no RCTs supporting the use of oral beta blockers or diltiazem for prevention of recurrent AVRT, although clinical experience suggests the drugs are effective, with a favorable side effect profile.287 Patients with pre-excitation may develop AF during an episode of AVRT and be exposed to increased risk of rapid conduction over the accessory pathway while receiving beta blockers, diltiazem or verapamil, so these agents must be used with caution.269 The decision to treat with these agents should follow a discussion of risks with the patient. Although evidence of poor anterograde conduction via the accessory pathway may be reassuring, rapid conduction in AF has been described even in the setting of intermittent anterograde conduction.291 IIb C-LD 4. Oral digoxin may be reasonable for ongoing management of orthodromic AVRT in patients without pre-excitation on their resting ECG who are not candidates for, or prefer not to undergo, catheter ablation.292 See Online Data Supplement 12. One small study reported the usefulness of oral digoxin in prevention of recurrent orthodromic AVRT in patients without pre-excitation on their resting ECG (concealed accessory pathway).293 Digoxin has been used clinically for many years, but the low efficacy indicates its use would be best limited to patients who are not candidates for catheter ablation or prefer pharmacological therapy and have failed to respond to other antiarrhythmic drugs. III: Harm C-LD 1. Oral digoxin is potentially harmful for ongoing management in patients with AVRT or AF and pre-excitation on their resting ECG.271 See Online Data Supplement 12. Digoxin shortens the refractory period of the accessory pathway, such that AF may induce ventricular fibrillation.271 Even if AF has never been documented, AVRT may degenerate into AF. Thus, oral digoxin should not be used to treat patients with a manifest accessory pathway. Recommendations for Ongoing Management of Orthodromic AVRT (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026