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.