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.......................... Invasive screening with an EPS should be performed in patients with asymptomatic pre-excitation who either have high-risk occupations or are competitive athletes (Figure 22). Variables on the EPS that identify patients with a high-risk AP include a SPERRI <_250 ms, AP ERP <_250 ms, multiple APs, and an inducible AP-mediated tachycardia in the baseline state or during isoproterenol infusion, which should always be tried.452,460 The options for screening patients who do not fall into these groups include the use of EPS as a risk-stratifying tool or the use of non-invasive screening with exercise testing, drug testing, and ambulatory monitoring as risk-stratification tools.

If a patient undergoes screening with an EPS and is found to have an AP with ‘high-risk’ characteristics, catheter ablation should be performed. Catheter ablation of an AP, when performed by an experienced operator, is associated with a high cure rate (>95%) and low risk (<0.5%) of major complications (see also Section 11.1.2.3).438440 However, it should be noted that even invasive

©ESC 2019

Asymptomatic pre-excitation

Yes No

No

Yes

Yes

No

Catheter ablation

(I C)

Clinical follow-up

(IIa C) Catheter ablation

(IIb C)

EPS for risk stratification

(IIa B) Non-invasive risk stratification

(IIb B) High-risk features

Low-risk features

High-risk occupation or competitive athlete?

EPS for risk stratification

(I B)

Figure 22 Risk stratification and therapy of patients with asymptomatic pre-excitation. High-risk features at electrophysiology study are shortest preexcited RR interval during atrial fibrillation <_250 ms, accessory pathway effective refractory period <_250 ms, multiple accessory pathways, and inducible atrioventricular re-entrant tachycardia. Low-risk features at non-invasive risk stratification are induced or intermittent loss of pre-excitation on exercise or drug testing, resting electrocardiogram, and ambulatory electrocardiogram monitoring. EPS = electrophysiology study. Downloaded from academic.oup.com/eurheartj/article/41/5/655/5556821 by guest on 07 October 2026