exercise-associated syncope matt baird, md shcc sports medicine symposium june 5 th, 2015 steadman...
Post on 24-Dec-2015
214 Views
Preview:
TRANSCRIPT
Exercise-associated Syncope
Matt Baird, MD
SHCC Sports Medicine Symposium
June 5th, 2015
Steadman Hawkins Clinic of the Carolinas
Objectives
• Briefly review the differential
diagnosis for syncope in the athlete.
• Discuss which patients require
removal from sport and urgent
workup.
Definition
• Syncope: Sudden,
transient loss of
consciousness
associated with
inability to
maintain postural
tone
Pathophysiology• Some inciting event causes
a drop in cardiac output
reducing oxygen and
substrate delivery to the
brain.
• Resultant reclined position
and autonomic
autoregulatory centers
reestablish perfusion
resulting in spontaneous
return of consciousness.
Epidemiology
• Syncope from all causes:
– 3% of ED visits
– ~30% admission rate
– 0.05% of pediatric visits, but 6% of admissions
• 3-20% of cases are associated with
exertion
• Vast majority are due to benign causes
Differential Diagnosis
• Benign:
– Neurocardiogenic syncope
• Life Threatening
– Cardiac
– Heat stroke/collapse
– Hyponatremia
– Anaphylaxis
– PE
– Subarrachnoid hemorrhage
Fieldside Evaluation
• Vital signs
• Exam:
– Usually unrevealing
–Maybe a murmur
• What’s the point?
– Almost all information comes from the
history
Bad or Not Bad• Most important
question:
– WHEN did syncope occur?
• Second most important
question:
– Were there any preceding
symptoms?
• Dizziness, nausea, light-
headedness
• Chest pain?
• Acute onset headache?
What we’ve been taught
• Syncope during exersion is bad.
• Syncope without preceding symptoms is more
likely to be due to cardiac abnormality.
• Chest pain?
– Consider PE, MI
• Sudden onset headache or focal neuro deficits
– Consider SAH
Evidence
• Holtzhausen LM, Noakes TD, Kronig B, et al.
Clinical and biochemical characteristics of
collapsed ultra-marathon runners. Med Sci
Sports Exerc. 1994;26:1095-101
– 46 male runners with EAC
– 85% after finishing race
– 15% during race were much more likely to have
organic pathology (cardiac abnormality,
hyperthermia, hyponatremia)
Evidence
• Colicicchi F, Ammirati F, Santini M.
Epidemiology and prognostic implications of
syncope in young competing athletes. Eur
Hear J. 2004 Oct;25(19):1749-53
– 7568 athletes screened with PPE
– 474 (6.2%) reported syncope
– 63 (0.83%) had EAS
– 57 of these were post-exertional
Evidence
• Colicicchi F, Ammirati F, Santini M.
Epidemiology and prognostic implications of
syncope in young competing athletes. Eur
Hear J. 2004 Oct;25(19):1749-53
– 6 athletes with syncope during exertion
• 1 HCM
• 1 ARVD
• 4 neurocardiogenic syncope
• All 6 were shut down
Evidence
• Colicicchi F, Ammirati F, Santini M.
Epidemiology and prognostic implications of
syncope in young competing athletes. Eur
Hear J. 2004 Oct;25(19):1749-53
– All other athletes with syncope were followed
for 3-10 years
• No adverse events
• Some recurrences
Take Home Point
• Syncope during
exercise is bad.
• Syncope after
completing
exercise is almost
always not bad.
Evidence
• Calkins et al. The value of clinical history in the
differentiation of syncope due to ventricular tachycardia,
atrioventricular bock, and neurocardiogenic syncope. Am J
of Med. April, 1995: 19 (4): 365-373
– Retrospective study of 80 patients
– Features of clinical history predictive of a cardiac cause:
• Male sex
• Age > 54
• 2 or less episodes of syncope
• Duration of warning symptoms <5 seconds
– Features suggestive of neurocardiogenic syncope
• palpitations, blurred vision, nausea, warmth, diaphoresis, or
lightheadedness prior to syncope
• nausea, warmth, diaphoresis, or fatigue following syncope
Evidence
– San Francisco Syncope Rule (Quinn et al,
2004)
•History of CHF
• Hct<30
• Abnormal ECG
• Shortness of breath
• SBP<90
Evidence
– Short-Term Prognosis of Syncope Study
(Constantino, et al. JACC 2008)
• Abnormal ecg (best)
• Concomitant trauma
• Absence of prodrome
• Male gender
Evidence• What can we extrapolate from non-athlete
studies/guidelines?
– ROSE (Risk Stratification of Syncope in the ED) Study
(Reed, et al, JACC 2010)
• BNP>300
• Fecal occult blood
• Anemia
• Chest pain with syncope• ECG
• O2 Saturation < 94% on RA
Take Home Point
• There are accepted risk factors to keep an
eye out for.
– Lack of prodromal symptoms
• chest pain
• ? Acute onset headache
– Abnormal vital signs
• Hypoxia
• Hypotension
– Medical history
• Age
• CHF
Summary
• Take syncope during exertion very
seriously.
– Hold from exertion
– Urgent cardiology referral
• Syncope after exercise is usually benign
• Look out for higher risk features
• Use common sense
References• Calkins H, Yu Shyr MS, Frumin H, Schork A, Morady F. The value of clinical history in the
differentiation of syncope due to ventricular tachycardia, atrioventricular bock, and
neurocardiogenic syncope. Am J of Med. April, 1995: 19 (4): 365-373
• Colivicchi F, Ammirati F, Santini M. Epidemiology and prognostic implications of syncope in
young competing athletes. Eur Heart J. 2004 Oct;25(19):1749-53
• Costantino G, Perego F, Dipaola F, et al. Short- and long-term prognosis of syncope, risk
factors, and role of hospital admission: results from the STePS (Short-Term Prognosis of
Syncope) study. J Am Coll Cardiol. 2008 Jan;51(3):276-83.
• Hastings JL, Levine BD. Syncope in the athletic patient. Prog Cardiovasc Dis. 20012 Mar-
Apr;54)5):438-44
• Holtzhausen LM, Noakes TD, Kroning B, de Klerk M, Roberts M, Emsley R. Clinical and
biochemical characteristics of collapsed ultra-marathon runners. Med Sci Sports Exerc.
1994;26:1095–101
• O’Connor FG, Levine BD, Childress MA, Asplundh CA, Oriscello RG. Practical management: a
systematic approach to the evaluation of exercise-related syncope in athletes. Clin J Sports
Med. 2009 Sep;19(5)429-34
• Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San
Francisco Syncope Rule to predict patients with short-term serious outcomes. Ann Emerg
Med. 2004 Feb;43(2):224-32.
• Natarajan B, Nikore V. Syncope and near syncope in competitive athletes. Curr Sports Med
Rep. 2006 Dec;5(6):300-6
• Reed MJ, Newby DE, Coull AJ, et al. The ROSE (risk stratification of syncope in the
emergency department) study. J Am Coll Cardiol. 2010 Feb;55(8):713-21.
top related