What is your approach to risk stratification of asymptomatic patients with pre-excitation syndrome?

When addressing pre-excitation on EKG, some good references include:

• ACC online expert analysis
• 2012 PACES/HRS expert consensus statement
• Editorial on the 2012 PACES guidelines about the challenges of being more aggressive

In general, I agree with Dr. @Dr. First Last and the ACC expert analysis that ambulatory EKG +/- treadmill for loss of pre-excitation can be helpful. That being said, the expert analysis points out higher risk features (males, athletes, high-risk occupation, young/first 2 decades of life) where we might lean toward EP study sooner. In a 2020 Heart Rhythm multicenter study of pediatric patients by Escudero et al., PMID 32497761, showed loss of pre-excitation had lower risk of high risk pathway but did not eliminate risk of...

I like getting a stress test and ambulatory ecg to see how preexcitation is affected by higher heart rates. Many accessory pathways do not have particularly robust conduction antegrade which is the key factor in whether or not atrial fibrillation can lead to life-threatening tachycardia.