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Exercise-Induced Syncope: Diagnosis and Management

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Title: Exercise-Induced Syncope: Diagnosis and Management


1
Exercise-Induced SyncopeDiagnosis and Management
  • Francis G. OConnor, MD, FACSM
  • Primary Care Sports Medicine

2
Objectives
  • Review the epidemiology of sudden death and
    exercise-induced syncope in athletes
  • Discuss the pathophysiology and differential
    diagnosis of exertional collapse
  • Discuss the evaluation and management of the
    athlete with exercise-associated collapse

3
Definitions
  • Syncope a sudden and temporary loss of
    consciousness, in the absence of head trauma,
    that is associated with a loss of postural tone
    with spontaneous recovery not requiring
    electrical or chemical cardioversion
  • Exercise-Induced Syncope
  • Exercise-Associated Collapse

4
Exercise-Induced Syncope
  • Syncopal episode during exercise or in the
    immediate post-exertional period the athlete
    normally recovers quickly

5
Exercise-Associated Collapse
  • Athlete is unable to stand or walk unaided as a
    result of lightheadedness, faintness, dizziness,
    or syncope.

6
Epidemiology of Exertional Sudden Death and
Syncope
7
Sudden Death in Older Athletes
8
Sudden Death in Younger Athletes
9
Nontraumatic Sports Death in High School and
College Athletes
  • VanCamp SP, et al Medicine and Science in Sports
    and Exercise 1996. Vol 27(5)641-7.

10
  • estimated death rates in male athletes were
    fivefold higher than in female athletes (7.5 vs.
    1.33)
  • estimated death rates were twofold higher in male
    college athletes than in male high school
    athletes
  • noncardiac causes of death accounted for 22 of
    the cases
  • male football and basketball accounted for the
    majority of deaths (104/160)

11
Risk for Sudden Cardiac Death Associated with
Marathon Running
  • Maron BJ,et alJournal of the American College of
    Cardiology 199628428-431.

12
  • 215,413 completed the Marine Corps and the Twin
    Cities Marathon
  • four exercise-related sudden deaths occurred
    three during the race, one right after completion
  • risk for sudden death with marathon running
    150,000 this was 1/100 the risk of overall
    living for 1 year

13
Syncope in Children and Adolescents
  • Driscoll DJ, et al Journal of the American
    college of Cardiology 1997291039-45.

14
  • population-based review of syncope in children
    and adolescents
  • 194 cases studied 3 presented with exertional
    syncope, with one subsequent sudden death
  • conclusions
  • electrocardiography warranted in all patients
    with syncope
  • detailed evaluation should be considered for
    patients with syncope with exercise, a family
    history of syncope, premature sudden death or
    arrhythmias

15
Screening for Hypertrophic Cardiomyopathy in
Young Athletes
  • Corrado D, et al The New England Journal of
    Medicine 1998339364-9.

16
  • prospective study of sudden death events among
    athletes and nonathletes
  • the incidence of sudden death from HCM was
    decreased in the athletes who had PPE screens
  • most common cause of sudden death in athletes was
    arrhythmogenic right ventricular dysplasia
  • 7 of the 28 athletes who died had complained of
    syncope none of the victims complained about
    exertional chest pain

17
Exertional Sudden Death in Soldiers
  • Drory Y et al Medicine and Science in Sports
  • and Exercise 1991. Vol 23(2) 147-151.

18
  • All exercise-related sudden unexpected deaths of
    soldiers 18-29 in the IDF during 1974-1986 were
    reviewed
  • twenty male soldiers died suddenly within 24hr of
    strenuous exercise
  • 70 of the victims had prodromal symptoms within
    one month of their demise with syncope being the
    most common complaint (40)
  • syncope was associated with HCM, myocarditis,
    intracranial hemorrhage, and heat stroke

19
Clinical and Biochemical Characteristics of
Collapsed Ultramarathon Runners
  • Holtzhausen LM, Noakes TD et al Medicine and
    Science in Sports and Exercise 1994. Vol
    26(9)1095-1101.

20
  • 56 km race 65 controls 46 runners with
    exertional collapse
  • most cases of EAC occurred at the finish line
    (85) correlation with cutoff for medals and
    race closure
  • 15 collapsing during the event had readily
    identifiable medical diagnoses asthma angina
    hypoglycemia gastroenteritis
  • states of dehydration, plasma renin and
    vasopressin concentrations were comparable in
    controls and EAC victims

21
Pathophysiology of Exercise-Associated Collapse
22
  • Multifactorial
  • Cardiovascular changes with exercise
  • Second Heart
  • Orthostatic intolerance in Athletes

23
Cardiovascular Regulation with Exercise
  • aerobic exercise results in dramatic shifts in
    blood distribution
  • cardiac ouput increases to accommodate an
    increase in peripheral oxygen demand
  • there is a preferential redistribution of blood
    flow to the working muscles and away from
    non-exercising areas

24
The Second Heart
  • During exercise the skeletal muscle functions as
    a second heart as the pumping action of
    skeletal muscle maintains venous return
  • During muscle contraction, the veins are emptied
    and the driving pressure back to the heart is
    substantially increased
  • If the the pumping action of skeletal muscle is
    lost despite a persistent vasodilation, syncope
    may ensue

25
Orthostatic Intolerance in Athletes
  • Endurance trained athletes have a reduced
    capacity to compensate for any acute hypotensive
    stress
  • Luft et al report that the incidence of syncope
    during lower body negative pressure is greater in
    trained than in untrained controls
  • Smith et al postulate training induced
    alterations in the autonomic nervous system with
    attenuated sympathetic activity to hypotensive
    stress in athletes

26
The Prevalence and Significance of Post-Exercise
Hypotension in Ultramarathon Runners
  • Holtzhausen LM, Noakes TD, et al Medicine and
    Science in Sports and Exercise 199527(12)1595-16
    01.

27
  • Study involving 31/240 runners in an 80k
    ultramarathon (mean age 38.9 years)
  • Pre- and Post-race weights, supine and erect
    blood pressures, and blood samples
  • osmolality
  • chemistries
  • glucose

28
  • Average weight loss was 3.5 kg (4.6)
  • Large increase in supine-erect blood pressure
    differences after the race
  • 81 of runners demonstrated a posture-related
    difference in systolic blood pressure in excess
    of 20mmHg
  • No significant correlation was found with weight
    loss, or plasma volume with systolic blood
    pressure differences

29
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30
  • Systolic and diastolic BP were decreased after
    exercise, but to a much greater extent in the
    erect versus supine position
  • Level of dehydration was unrelated to the degree
    of postural hypotension
  • EAC should initially be treated with pelvic and
    lower limb elevation, not IV rehydration

31
Exercise Associated Collapse
  • Postulated Mechanism for EAC
  • redistribution of blood flow to working muscle
    and skin
  • reliance of skeletal muscle pump to maintain
    atrial filling pressure
  • sudden cessation of exercise of exercise promotes
    peripheral pooling

32
Exercise Associated Collapse
  • Postulated Mechanism for EAC
  • contractions of empty ventricle stimulate
    mecchanoreceptors
  • afferent vagal C-fibers transmit these signals to
    the CNS with efferent reflexes result in
    vasodilatation and bradycardia with syncope

33
Exercise Associated Collapse
  • In summary, syncope after exercise is
    multifactorial but can usually be explained by
    predictable hemodynamic responses
  • heat stress
  • extraordinary effort
  • standing quietly in an upright position

34
Differential Diagnosis of Exertional Syncope
35
Differential Diagnosis of Syncope
Mean Arterial Pressure
Cerebral Metabolism
  • Heart Rate
  • Stroke Volume
  • Peripheral Resistance
  • Tissue Oxygen
  • Substrate Delivery

36
Differential Diagnosis
  • Cerebral Metabolism
  • seizure
  • hypocapnia
  • hypoxia
  • hypoglycemia
  • hyperthermia

37
Differential Diagnosis
  • Heart Rate too Slow
  • bradyarrhythmia
  • cardioinhibitory reflex (neurocardiogenic)
  • conduction abnormality

38
Differential Diagnosis
  • Heart Rate too Fast
  • supraventricular
  • pre-excitation
  • atrial fibrillation
  • ventricular
  • ventricular tachycardia
  • ventricular fibrillation

39
Differential Diagnosis
  • LVEDV too Low
  • pulmonary hypertension
  • pulmonic stenosis
  • dehydration
  • hemorrhage

40
Differential Diagnosis
  • LVESV too High
  • aortic stenosis
  • hypertrophic cardiomyopathy
  • ischemia

41
Differential Diagnosis
  • TPR too Low
  • vasodepressor reflex
  • anaphylaxis
  • functional sympatholysis

42
Evaluation and Management of the Athlete with a
History of Exertional Syncope
43
Assessment
  • History and Physical Examination
  • Electrocardiogram
  • Special Tests
  • Echocardiography
  • Exercise Stress Testing
  • Putting it All Together

44
History
  • True syncope versus exercise associated
    collapse
  • During versus immediately after exercise
  • Prodromal symptoms
  • Post-event state
  • Medications
  • High risk behaviors
  • Family history

45
Physical Examination
  • Vital signs supine and upright (at least 5
    minutes standing)
  • BP in arms/legs
  • Body habitus
  • Cardiac murmurs at rest and during Valsalva or
    rise from squatting position

46
Electrocardiogram
  • QTc
  • Pre-excitation
  • ST-T wave abnormalities
  • Ischemic changes
  • T wave inversion v1 -v3
  • Ectopy, inparticular with LBBB

47
Echocardiogram
  • LV and RV size and function
  • Valve structure
  • Left main coronary ostial position
  • Aortic annulus size
  • Pulmonary systolic pressure

48
Exercise Stress Test
  • Designed to reproduce conditions which provoked
    the event e.g.
  • start-stop
  • prolonged high intensity
  • Appropriate QT shortening

49
Putting it All Together
50
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51
Evaluation and Management of the Athlete with
Acute Exercise-Associated Collapse
52
Collapsed Ultraendurance Athlete Proposed
Mechanisms and an Approach to Management
  • Holtzhausen LM, Noakes TD Clinical Journal of
    Sports Medicine 19977292-301.

53
Conditions Associated with Collapse during or
after Prolonged Exercise
  • Hypothermia
  • Hyponatremia
  • Cardiac arrest
  • Other medical conditions
  • Orthopedic conditions
  • Exercise-associated collapse
  • Muscle cramps
  • Heat stroke
  • Hypoglycemia

54
Initial Management of Collapsed Athletes
  • Noakes Fallacy 1 All persons who collapse after
    exercise have dehydration-induced hyperthermia
  • Treatment by necessity is most often initiated in
    the absence of a diagnosis
  • Appropriate Triage
  • level of consciousness
  • site of collapse
  • vital signs HR, BP, rectal temp

55
Severity of the Collapsed Athlete
  • Nonsevere
  • Immediate Assessment
  • conscious
  • alert
  • rectal temp lt40C
  • systolic BP gt100 mmHg
  • heart rate lt100 bpm
  • Specialized Assessment
  • glucose 4 -10 mmol/L
  • sodium 135 -148 mmol/l
  • wt loss 0 -5
  • Severe
  • Immediate Assessment
  • unconscious or altered mental state
  • confused, disoriented
  • rectal temp gt40C
  • systolic BP lt100mmHg
  • heart rate gt100 bpm
  • Specialized
  • glucose lt4 or gt10 mmol/L
  • sodium lt130 or gt148 mmol/l
  • wt loss gt10

56
Management of Collapsed Athletes who are
Unconscious
  • Universal Algorithm for Adults
  • ABCs
  • Differential Diagnosis
  • Medical vs. Exercise-related
  • Vital Signs
  • Clinical Judgement

57
Universal Algorithm for Adults
Assess Responsiveness
  • Responsive
  • Observe
  • Treat as Indicated
  • Not Responsive
  • Activate EMS
  • Call for defibrillator
  • Assess breathing
  • Not Breathing
  • Give 2 slow breaths
  • Assess circulation
  • Breathing
  • Place in recovery position
  • Rescue breathing
  • Oxygen, endotracheal intubation
  • Vital signs, IV, Monitor
  • History and Physical

Pulse
No Pulse
Start CPR
58
Management of Collapsed Athletes who are
Unconscious
  • Medical Condition not Necessarily Related to
    Exercise
  • cardiac arrest
  • diabetic coma
  • subarachnoid hemorrhage
  • grand mal epilepsy
  • Exercise-Related Disorder
  • hyponatremia
  • heat stroke
  • severe hypoglycemia

59
Differential Diagnosis
  • Heat Stroke
  • unconscious
  • altered mental state
  • T gt41C
  • tachycardia
  • hypotension
  • Hyponatremia
  • unconscious
  • altered mental state
  • Tlt40C
  • NL V/S

60
Initial Management
  • Heat Stroke
  • ABCs
  • IV, monitor
  • Immediate cooling to 38C
  • Normal saline
  • Transfer
  • Hyponatremia
  • ABCs
  • IV, monitor
  • Isotonic/hypertonic saline lt50ml/hr
  • avoid overhydration
  • transfer

61
Management of Collapsed Athletes who are
Conscious
  • Clinical Assessment
  • altered mental status
  • pertinent history
  • state of hydration
  • vital signs
  • rectal temp
  • blood pressure
  • heart rate
  • orthostatics

62
Management of Collapsed Athletes who are
Conscious
  • Pertinent History
  • amount of fluid ingested during the race
  • amount of urine passed during the race
  • vomiting and/or diarrhea
  • carbohydrate ingested before and during the race
  • drugs taken during the race
  • recent illness
  • race preparation

63
Management of Collapsed Athletes who are
Conscious
  • Exercise-Associated Collapse
  • diagnosis of exclusion
  • ingest oral fluids
  • elevate legs and pelvis
  • cool as indicated
  • monitor vital signs
  • most athletes asymptomatic within 30 minutes

64
Management of Collapsed Athletes who are
Conscious
  • Who needs an IV?
  • unconscious
  • suspected heat stroke, hyponatremia, hypoglycemia
  • physical exam c/w dehydration
  • persistent emesis
  • persistent tachycardia and hypotension when
    lying supine with legs and pelvis elevated gt10 to
    15 minutes

65
Conclusions
  • EAC is common, and most often benign
  • Exercise-induced syncope, however, particularly
    during exercise, may be a harbinger of a sudden
    death event
  • Management of the young athlete requires an
    astute clinician who incorporates judgement with
    an appropriate history and physical
  • Always treat the patient first and the athlete
    second

66
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67
You find what you look for, and diagnose what
you know!
  • Jack Hughston, MD

68
Compression
  • No RCTs isolating effect of compression
  • Compression wraps with malleolar horseshoes to
    decrease swelling
  • When combined with appropriate elevation, thought
    to limit swelling and result in a faster recovery

69
Putting it All Together
  • Assessment
  • History
  • Physical Examination
  • Electrocardiogram
  • Selected Laboratory Tests

70
Putting it All Together
  • Diagnostic
  • Suggestive
  • Unexplained

71
Putting it All Together
  • Diagnostic or Suggestive
  • Potentially life-threatening
  • Restriction vs. treat or evaluate
  • Consider Referral

72
Putting it All Together
  • Unexplained
  • Restriction
  • ECHO/GXT
  • Reassurance vs. Referral
  • Post-exertional
  • Non-recurrent
  • Normal family history
  • Normal cardiac examination
  • Normal ECG, ECHO, GXT
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