9 Frequently, these patients describe a prodrome of lightheadedness, pallor, a feeling of warmth, diaphoresis, and nausea or epigastric pain. 8 Vasovagal syncope, considered a benign condition, typically occurs when going from a sitting to standing position, or experiencing fear or emotional distress with specific triggers such as sight of blood or trauma. 7 This form of syncope (frequently referred to as neurocardiogenic, or reflex or vasovagal syncope) is largely neurally mediated with poorly understood pathophysiology. Syncope unrelated to exercise is the most common presentation, accounting for more than 85% of cases. It is helpful to classify athletes with syncope into three cohorts based on the chronological context of the syncopal episode: syncope unrelated to exercise, post-exertional syncope, and exertional syncope. 7 The differential diagnosis for a syncopal event is broad, with the large majority of episodes secondary to a benign cause, and only a small subset attributable to the presence of underlying structural heart disease. One study of athletes undergoing preparticipation screening reported 474 out of 7,568 (6.2%) athletes experienced syncope in the preceding five years. Thus, an accurate and comprehensive understanding of syncope in athletes is crucial in order to avoid tragic outcomes and prevent placement of undue restrictions on healthy individuals. Second, long-term removal from athletic activities can result in dramatic emotional and psychological distress. First, since athletes are considered symbols of exceptional health, sudden deaths − let alone syncope − are especially shocking and frequently make headlines. The athlete represents a unique population in the context of the evaluation and management of syncope for two important reasons. 6 As such, syncopal spells account for a significant portion of emergency department visits and hospitalizations placing a substantial burden on the American healthcare system. Syncope is a common and often challenging clinical problem with an estimated lifetime prevalence of ~40% in the general population. It is also important to distinguish syncope from other causes of loss of consciousness such as seizures, metabolic disorders and stroke or transient ischemic attacks. 5 Presyncope, in contrast to syncope, is the presence of lightheadedness, dizziness, or weakness that almost results in loss of consciousness. Syncope, defined as a transient loss of consciousness due to global cerebral hypoperfusion, is characterized by spontaneous and complete recovery. 4 In this expert analysis, the authors will review the management of the athlete presenting with syncope. 3 Since the publication of that article, the scientific community has made large strides toward meeting that charge in the form of the 16 th, 26 th, 36 th Bethesda conferences, and most recently the Eligibility and Disqualification Recommendations for Competitive Athletes with Cardiovascular Abnormalities published in December 2015. Barry Maron published an article in the New England Journal of Medicine calling for standardized criteria to better risk stratify and appropriately disqualify athletes at increased risk for sudden death. This tragic story, alongside other famous athletes who died unexpectedly, has served as an impetus to research and better understand cardiac evaluation of athletes over the last three decades. In fact, some reports suggest he had not been taking any medication on game days. Unfortunately, due to increased fatigue and reduced performance capacity, he did not tolerate higher doses of the medication and dosing was gradually weaned. Extensive testing including cardiac catheterization, electrophysiology (EP) studies, and ambulatory cardiac event monitoring revealed underlying exercise-related complex ventricular tachyarrhythmias for which he was treated with propranolol. 1 Noteworthy, a few months before his death, he had syncope during a game. At 6’7” and 210 lbs, was leading the NCAA 1989-89 basketball season in both scoring (32.7 PPG) and rebounds (13.7 RPG). Mamarked the 26 th anniversary of the death of an elite college basketball player at Loyola Marymount University who suddenly collapsed and died during a televised intercollegiate basketball game at the age of 23.
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