Conflicts of interest: None

Syncope in Athletes Thomas G. Allison, PhD, MPH Mayo Clinic Rochester, MN USA 13 th Annual Review Course in Clinical Cardiology Zurich 14 April, 2015 CP972908-1

Conflicts of interest: None

Syncope: Definition Syncope is a symptom, defined as a transient, self-limited loss of consciousness, usually leading to falling. The onset of syncope is relatively rapid, and the subsequent recovery is spontaneous, complete, and usually prompt. The underlying mechanism is a transient global cerebral hypo-perfusion. 2 peaks: Lifetime incidence 35% Age 15-20 Age 75-80

Magnitude of Syncope National Disease and Therapeutic Index on Syncope and Collapse: ICD-9-CM 780.2, IMS America, 1997Gendelman HE et al: NY State J Med, 1983 1-6% of admissions 3% of emergency room visits per year Day SC et al: Am J of Med, 1982 Kapoor W: Medicine 69:160-75, 1990 CP972908-4

Prevalence and Causes of Syncope Framingham Heart Study N= 822 Medication 6.8% Orthostatic 9.4% Other 7.5% Cardiac 9.5% Vasovagal 21.2% Unknown 36.6% Seizure 4.9% Stroke or transient ischemic attack 4.1% Soteriades et al. NEJM 2002 CP1096612-1

Syncope Evaluation: Challenges Patients usually asymptomatic during evaluation Potential causes range from benign etiologies to life-threatening conditions Concerns that well-appearing" patients may be at risk of significant arrhythmia and sudden death often result in extensive broad-based evaluations and frequent hospital admissions Especially in athletes

Syncope in Athletes Athletes may be different Age, fatigue, environmental and emotional factors But athletes are healthy and fit, often pre-screened Review of 7568 young athletes 5132 M, 2436 F Age 16.2 ± 2.4 474 (6.2%) had syncope in previous 5 years Unrelated with exercise in 411 athletes (86.7%), Post-exertional in 57 athletes (12.0%) Exertional in 6 athletes (1.3%) 1 case of HCM, 1 case of ARVD Colivicchi F et al. EHJ 2002; 1749 1753 2012 MFMER slide-7

Syncope in Athletes 1. Post-exercise collapse Vasodilatation, fatigue, dehydration, hyperthermia 2. Vasovagal syncope 3. Cardiac syncope 4. Exercise swoon Athlete stops performing Slowly collapses Not complete LOC marginally responsive Prolonged episode, slow recovery 2012 MFMER slide-8

Clinical Features Suggestive of Specific Causes of Syncope Cardiac syncope During exertion* or while supine Preceded by palpitations or accompanied by chest pain Presence of severe structural heart disease Older age History of coronary artery disease Family history of sudden death * Syncope during exercise (5% of cases) predicts cardiac cause with odds ratio of 3:1 and sensitivity of 96% Alboni et al. JACC 2001;37:1921-1928

Clinical Features Suggestive of Specific Causes of Syncope Syncope due to orthostatic hypotension After standing up After a meal Temporal relationship with start of medication leading to hypotension or changes of dosage Prolonged standing especially in crowded, hot places Presence of autonomic neuropathy or Parkinsonism After exertion

Clinical Features Suggestive of Specific Causes of Syncope Neurally-mediated syncope Absence of cardiac history Long history of syncope After unpleasant sight, sound, smell or pain Prolonged standing or crowded, hot places Nausea, vomiting associated with syncope During or in the absorptive state after a meal With head rotation, pressure on carotid sinus (as in tumors, shaving, tight collars) After exertion

Mechanism of Vasovagal Syncope Syncope Orthostatic hypotension Vasovagal Sympathetic Parasympathetic Bradycardia Cardiovagal Pain Bad smell Urination Cardiovascular Center Brain stem Cough Bad taste Arousal 2012 MFMER slide-12

Symptoms associated with vasovagal syncope Nausea Vomiting Feels hot or cold Sweating Tinnitus Confusion Tunnel vision Stuttering Chest discomfort Loss of urine Seizure if head remains above heart 2012 MFMER slide-13

Diagnosis and Management of Syncope in Athletes Step 1 (important): Rule out cardiac syncope Careful history Review of event Personal history of exercise and symptoms Family history Physical exam Murmurs 2012 MFMER slide-14

Value of Tilt Table Testing? 80% reproducible in patients with vasovagal syncope What is the specificity? Very few normal subjects undergo tilt testing Outcomes not different between syncope patients with positive and negative tilt test Does a positive tilt test rule out cardiac syncope? Hickam s Dictum Patient can have both kinds of syncope Sheldon et al Am J Cardiol 1997;80:581-585 CP972908-42

Diagnosis and Management of Syncope in Athletes Cardiac tests EKG Echocardiogram Stress test Holter monitor Event recorder Loop recorder EP study CT angiogram Treat and play versus disqualify? 2012 MFMER slide-16

Mayo Clinic Long QT Clinic Michael Ackerman, MD 157 athletes with confirmed channelopathies evaluated and counseled 27 self-disqualified 130 continued participation with appropriate therapies (medical therapy, AICD, sympathectomy) 650+ person years of follow-up 0 deaths 1 patient with AICD shocks Johnson and Ackerman JAMA 2012;38:764-765 2012 MFMER slide-17

Johnson and Ackerman JAMA 2012;38:764-765 2012 MFMER slide-18

Case 1 34-y.o. woman training for triathlon Syncopal episode at 80-minute mark of 2 hour swimming session Rescued from pool, awoke spontaneously at side of pool ~ 2 minutes after syncope Awake and alert when paramedics arrived Diagnosis? Cardiac syncope 2012 MFMER slide-19

2012 MFMER slide-20

Case 2 18-y.o. man first day of basic training (military) Awake at 0400 does 50 push-ups Collapses after standing in line for 3 minutes Promptly awake and alert Diagnosis? Post-exercise collapse (vasovagal) Note: this became a recurrent problem 2012 MFMER slide-21

Case 3 16-y.o. male high school football player (center) First day of summer practice After wind sprints, comes to huddle Feels heart pounding, becomes lightheaded Assisted by trainer to sideline, collapses Awake and alert within 5 seconds Heart continues to pound, taken to ED (resolves parking lot) Diagnosis? Cardiac syncope or post-exercise collapse? 2012 MFMER slide-22

EPS: Mahaim fiber

Diagnosis and Management of Vasovagal Syncope Step 1: Cardiac syncope has been excluded Step 2: First episode of vasovagal (or orthostatic) syncope Reassure and educate Risk factors for recurrence Prodromal symptoms Avoidance 2012 MFMER slide-24

Diagnosis and Management of Vasovagal Syncope Step 3: Recurrent syncope Identify triggers avoid or desensitize Prophylactic measures Medications Modify exercise training 2012 MFMER slide-25

Behavioral Aspects of Syncope When neurogenic syncope is recurrent or presyncope is chronic, learning is frequently involved Classical (Pavlovian) conditioning Behavioral therapy (desensitization) is often helpful (and necessary) Example Young man with syncope after push-ups Rx: start 1 push-up first day Move feet when standing in line Add 1 push-up per day Problem resolved in 6 weeks 2012 MFMER slide-26

Medical Treatment Options for Recurrent Vasovagal Syncope Fludrocortisone Midodrine Selective serotonin-reuptake inhibitor Beta blocker (propanolol) Tachycardia, chest pain present Older subjects without low BP Migraine present Limited data, small studies Regulatory, performance issues

Treatment Options for Recurrent Vasovagal Syncope in Athletes Recognize pre-syncope! sit /lie down Physical counterpressure maneuvers Maintain fluids and electrolyte intake 32-64 oz. electrolyte drink per day Fludrocortisone? Activity modifications Modification of exercise program

Physical Counterpressure Maneuvers

Activity Modifications: Weight Training No Yes 2012 MFMER slide-30

Exercise Program 2012 MFMER slide-31

Contact: allison.thomas@mayo.edu