Short PR Interval in Young Athletic Males: Evaluation and Management

Clinical Significance

A short PR interval (< 120 ms) without a delta wave can be a normal variant in athletes but may also indicate ventricular pre‑excitation (Lown‑Ganong‑Levine syndrome) or underlying structural heart disease such as hypertrophic cardiomyopathy or Fabry disease. [1][2][3][4]
Isolated short PR without a delta wave may represent either a benign variant (particularly common in athletes) or Lown‑Ganong‑Levine syndrome; careful evaluation is required to exclude structural disease. [1][2]

A focused history should inquire about symptoms such as palpitations, syncope or near‑syncope, chest discomfort associated with palpitations, and episodes lasting longer than 30 minutes. [2][3]
Family history should assess for pre‑excitation syndromes, cardiomyopathy, or sudden cardiac death in young relatives. [2][3]4

Transthoracic echocardiography is recommended to rule out hypertrophic cardiomyopathy, Ebstein anomaly, and glycogen‑storage cardiomyopathy (e.g., PRKAG2‑related familial WPW). [1][2]3
Exercise testing:
- Intermittent loss or sudden disappearance of pre‑excitation during exercise suggests a long anterograde refractory period of the accessory pathway and therefore a low risk of sudden death. [2][3]
- Exercise testing can also unmask latent pre‑excitation and help assess overall arrhythmic risk. [2][3]
24‑hour Holter monitoring:
- Detects paroxysmal tachyarrhythmias and monitors QTc trends over time.
- Documentation of intermittent pre‑excitation on ambulatory monitoring is associated with a lower risk profile. [2][3]
Pharmacological testing (vagal maneuvers, intravenous adenosine, or verapamil) may unmask typical WPW ECG features by slowing or blocking AV‑node conduction, aiding diagnosis when latent pre‑excitation is suspected. [2][3]

Low‑risk indicator: Abrupt loss of pre‑excitation during exercise testing suggests a benign course and may permit continued athletic participation. [2][3]
High‑risk features (e.g., shortest pre‑excited RR < 250 ms during atrial fibrillation, symptomatic tachycardia, multiple accessory pathways, Ebstein anomaly, accessory pathway refractory period < 240 ms) are not supported by cited evidence in this article and therefore are omitted.

Confirmed WPW (short PR with delta wave):
- Athletes with documented ventricular pre‑excitation should be referred for an electrophysiological study (transesophageal or intracardiac) to evaluate inducibility of AV‑re‑entrant tachycardia and accessory‑pathway refractory periods; results guide eligibility for competition, risk stratification, and consideration of catheter ablation. [1][2][3][4]
Isolated short PR without delta wave:
- In asymptomatic individuals with a normal echocardiogram and no high‑risk findings on exercise testing or Holter monitoring, the short PR interval is likely a benign variant; periodic surveillance with repeat ECG and clinical review is advised. [1][2]
Evidence strength: The cited European Heart Journal articles provide observational and expert‑opinion data; specific levels of evidence are not detailed in the source material.

A short PR interval is typically defined as less than 120 ms and may be associated with ventricular pre-excitation syndromes, according to the European Heart Journal 5, 6
The short PR interval occurs due to an accessory pathway that bypasses the AV node, allowing for early ventricular activation, as reported by the Journal of the American College of Cardiology 7

Short PR interval with a delta wave (widened QRS) indicates WPW syndrome, which carries a risk of sudden cardiac death due to rapid conduction of atrial fibrillation across the accessory pathway potentially leading to ventricular fibrillation, as stated by the Journal of the American College of Cardiology 7
An isolated short PR interval without delta wave or widened QRS may represent either a normal variant (particularly in athletes) or Lown-Ganong-Levine syndrome, according to the European Heart Journal 5, 6

The highest risk for sudden cardiac death in WPW is associated with a shortest pre-excited RR interval <250 ms during atrial fibrillation, history of symptomatic tachycardia, multiple accessory pathways, and presence of Ebstein's anomaly, as reported by Circulation 8

For patients with short PR interval with delta wave (WPW pattern), further evaluation should include assessment of symptoms, family history, echocardiography, risk stratification with exercise testing, and electrophysiological study, as recommended by the European Heart Journal and the Journal of the American College of Cardiology 5, 6, 7
For isolated short PR interval without delta wave, careful evaluation is still warranted as it may reflect either Lown-Ganong-Levine syndrome or underlying structural heart disease, according to the European Heart Journal 5, 6

For high-risk WPW (shortest pre-excited RR interval ≤250 ms during atrial fibrillation), catheter ablation is recommended by the Journal of the American College of Cardiology 7
Intermittent pre-excitation during sinus rhythm suggests a low-risk pathway, as reported by Circulation and the Journal of the American College of Cardiology 7, 8

Cardiac arrest is the first manifestation of WPW in approximately half of cases, emphasizing the importance of proper identification and risk stratification, as stated by Circulation 8
Non-invasive tests are considered inferior to invasive electrophysiological assessment for determining sudden cardiac death risk in WPW syndrome, according to Circulation 8