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©2013 UpToDate ® Print Email ACC/AHA/ESC guideline summary: Management of atrial fibrillation (AF) in Wolff-Parkinson-White (WPW) preexcitation syndromes Class I - There is evidence and/or general agreement that the following approaches are effective for the management of AF in patients with WPW syndrome •  Catheter ablation of the accessory pathway in symptomatic patients, particularly those with syncope due to a rapid heart rate or a short refractory period in the bypass tract. •  Immediate direct current (DC) cardioversion to prevent ventricular fibrillation in patients with a short refractory period in the bypass tract in whom AF occurs with a rapid ventricular response and hemodynamic instability. •  Intravenous procainamide or ibutilide to restore sinus rhythm when AF occurs in association with a wide QRS complex (≥120 msec) or a rapid preexcited ventricular response in patients who are hemodynamically stable. Class IIa - The weight of evidence or opinion is in favor of the usefulness of the following approach for the management of AF in patients with WPW syndrome •  Intravenous flecainide or DC cardioversion when rapid ventricular rates occur involving conduction over an accessory pathway. Class IIb - The weight of evidence or opinion is less well established for the usefulness of the following approach for the management of AF in patients with WPW syndrome •  Intravenous quinidine, procainamide, disopyramide, ibutilide, or amiodarone in hemodynamically stable patients with conduction over an accessory pathway. Class III - There is evidence and/or general agreement that the following approach is not useful or may be harmful for the management of AF in patients with WPW syndrome •  Intravenous digitalis or nondihydropyridine calcium channel blockers in patients with preexcited ventricular activation during AF. Data from: Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing committee to revise the 2001 guidelines for the management of patients with atrial fibrillation). J Am Coll Cardiol 2006; 48:e149.