Question 14#

An asymptomatic 32-year-old man has the ECG shown performed as part of a routine work medical examination.

A. This ECG shows right bundle branch block
B. He is asymptomatic and can be reassured without further investigation
C. He should have a 5 day monitor and as long as there are no significant arrhythmias or changes in the QRS complexes he can be reassured and discharged
D. He should have an echocardiogram and if this is normal he can be reassured and discharged
E. He should proceed to an EP study

Correct Answer is E


The ECG shows pre-excitation. Even though the patient is asymptomatic there is a risk of SCD due to pre-excited AF. There is no consensus on the best way to risk stratify patients, but if non-invasive testing is preferred a 5-day monitor could be performed. However, its main use is to see whether the pathway is intermittent with a sudden loss of pre-excitation which would place the patient in a lower risk category. In answer C there is no loss of pre-excitation during the 5-day monitor and therefore it would not be reasonable simply to discharge him. EP studies allow risk stratification and then the possibility of ablating a high-risk pathway at the same time.