Diagnostic Test Accuracy of Exercise Testing in Detecting High-Risk Accessory Pathways in WPW: A Systematic Review and Meta-Analysis.

Background: Wolff-Parkinson-White (WPW) syndrome is characterized by ventricular pre-excitation, which can lead to severe arrhythmic events such as supraventricular tachycardia and pre-excited atrial fibrillation. The diagnostic value of non-invasive exercise tests in detecting high-risk accessory pathways remains inconsistent in the literature.

Objectives: To evaluate the diagnostic accuracy of non-invasive exercise tests compared to invasive electrophysiological studies (EPS) for identifying high-risk accessory pathways in WPW syndrome.

Methods: Following PRISMA-DTA guidelines, a comprehensive search was conducted in PubMed, Scopus, and Web of Science databases. Eligible studies assessed the sensitivity, specificity, and likelihood ratios of non-invasive exercise tests in WPW patients, using EPS as the reference standard. A bivariate random-effects model was applied for meta-analysis.

Results: Six studies, comprising a total of 765 patients, met the inclusion criteria. The pooled sensitivity was 92.7% (95% CI: 88.0% - 94.0%), while the pooled specificity was 28.1% (95% CI: 23% - 35.1%). A negative likelihood ratio (LR-) of 0.260 (95% CI: 0.174 - 0.387) indicated that the presence of a high-risk accessory pathway is about four times less likely after a negative test result. Sensitivity analysis restricted to pediatric patients showed consistent results.

Conclusion: Non-invasive exercise tests demonstrate a reasonable diagnostic utility for ruling out high-risk pathways in WPW syndrome. However, caution is advised when using these tests as standalone criteria for risk stratification.