Syncope in Athletes:
When to Worry

Paul W. Baumert, Jr., M.D., FAAFP

Sports Medicine Rounds

August 24, 2006

“Faint signs of
Underlying Problems”

Case from last month

n    Basketball player

n    Lightheaded, tired, recent headache

n    Unilateral weakness

n   Atypical migraine

n   Conversion/factitious disorder

n   Something more serious

n    Initial labs, MRI negative

n    MRA: filling defect in MCA

n    Thrombotic source: Patent foramen ovale

Definition

n    Syncope

n    Temporary loss of consciousness and postural tone resulting from an abrupt, transient cerebral hypoperfusion from which recovery is spontaneous without chemical or electroconversion resuscitation

n    Near syncope/Presyncope

n    Sensation of eminent fainting

Background

n    Framingham study

n    >5000 men and women, ages 30-60, followed over 25 years

n    Syncope

n   At least one episode in about 3%

n   Not associated with stroke/TIA, MI, or sudden death

n   Unknown exact etiology in 40%!

n   30% had recurrent episodes

n    3% of ER visits and 6% of hospital admissions

Background

n    Syncope associated with exercise

n    Colivicchi et al

n   7568 athletes, 2/3 male & 1/3 female

n   Age 16.2 +/- 2.4 years

n   Postexertional syncope in 12%

n   Exertional syncope in 1.3%

n    Corrado et al

n   33,000 Italian athletes over 15 years

n   40/49 sudden death during/immed after exercise

n   7/40 with prior syncopal episodes

Causes of exertional syncope

n    Cerebral/metabolic

n    Arrhythmic

n    Structural

n    Neurocardiogenic

Cerebral/metabolic

n    Seizure disorder

n    Hypoglycemia

n    Hyponatremia

n    Hyperthermia

n    Hypoxia

Arrhythmic

n    Wolff-Parkinson-White (WPW)

n    Long QT syndrome

n    Congenital

n    Acquired

n    Arrhythmogenic right ventricular dysplasia (ARVD)

n    Polymorphic ventricular tachycardia

n    Brugada syndrome

Structural

n    Hypertrophic cardiomyopathy (HCM)

n    Arterial abnormalities

n    Coronary artery

n    Aortic stenosis

n    Valve abnormalities

n    Mitral valve prolapse

Neurocardiogenic

n    The most COMMON cause

n    Known as lots of different names

n    Vasovagal, etc.

n    Complex interaction of cardiovascular and neurologic elements in a reflex loop

n    Especially following a distressing stimulus or AFTER exertion

n    E.g. runner at the end of a cross-country race

When to Worry?

History is the KEY

n     Description of the event (does it make sense?)

n    Prodrome?  Triggers?  Time of day?  Hydration?

n    LOC?  Tonic/clonic or post-ictal?  Duration?

n    Witnesses?  Position of patient?  CPR?

n     Previous episodes

n     Detailed family history

n     An episode where the person was “out” for 3 hours is not going to have a cardiac etiology

n     All episodes of syncope in gym class are not exercise related

When to Refer to a Cardiologist

n    Episode DURING activity

n    Patient history of congenital heart disease

n    Family history

n    Sudden cardiac or unexplained death, especially at a young age

n    HCM, Long QT, WPW, ARVD, Brugada, etc.

n    Pacemaker or defibrillator under age 35 unrelated to a congenital heart disease

n    CPR performed by a reliable provider

Hawkeye Sports Medicine Symposium

 

December 1-2, 2006

Marriott Hotel & Conference Center

Coralville, Iowa