Wolff-Parkinson-White Pattern: Recognition of Ventricular Pre-Excitation and Risk Stratification

Background: Wolff-Parkinson-White (WPW) pattern is characterized by ventricular pre-excitation through an accessory atrioventricular pathway. Although often asymptomatic, some pathways carry a risk of tachyarrhythmia and sudden cardiac death. Case Description: A 45-year-old man with hypertension, polysubstance use, and bipolar disorder presented with altered mental status following suspected substance intoxication. His course was complicated by hypoxic respiratory failure requiring intubation and a large right basal ganglia hemorrhage requiring surgical evacuation. During hospitalization, an abnormal ECG prompted Cardiology consultation. The ECG demonstrated sinus rhythm with a short PR interval, delta wave, and widened QRS complex, consistent with ventricular pre-excitation. He had no documented tachyarrhythmia, palpitations, syncope, exertional symptoms, or family history of sudden cardiac death. Discussion: In the absence of symptoms or documented arrhythmia, the findings were consistent with an asymptomatic WPW pattern rather than WPW syndrome. Risk stratification is important because accessory pathways capable of rapid antegrade conduction can facilitate pre-excited atrial fibrillation and potentially ventricular fibrillation. Exercise testing may identify lower-risk pathways through abrupt loss of pre-excitation, while persistent or indeterminate pre-excitation may warrant electrophysiologic evaluation. Conclusion: This case emphasizes the importance of recognizing incidental ventricular pre-excitation and distinguishing WPW pattern from WPW syndrome. Appropriate risk stratification and follow-up can identify patients at increased arrhythmic risk and guide consideration of definitive catheter ablation.