MEDizzy - A 15-year-old male presents to your office on the advice of

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Cardiology

A 15-year-old male presents to your office on the advice of his football coach. The patient started playing football this year and suffered a syncopal episode at practice yesterday. He reports that he was sprinting with the rest of the team and became lightheaded. He lost consciousness and fell to the ground, regaining consciousness within one or two minutes. He suffered no trauma during the event. He has no prior history of head injury or recent illness. He has had no prior episodes of syncope. The patient is adopted and their family history is unavailable. Physical examination is unremarkable. What is the best course of action regarding this patient’s syncopal episode?

ExplanationThis patient is at risk of sudden cardiac death. Although syncope associated with strenuous activity is not an uncommon event in adolescence, benign syncope typically occurs after the exercise has finished. Syncope during exercise should raise the specter of hypertrophic obstructive cardiomyopathy. This uncommon anatomic abnormality results in restricted flow through the left ventricular outflow tract. Physiologic changes that increase contractility (exercise), decrease preload (dehydration), or decrease afterload may increase the pressure gradient across the outflow tract. An ECG may reveal LV hypertrophy although the sensitivity of ECG for diagnosis of LVH is relatively poor. Echocardiogram will reveal symmetric or asymmetric hypertrophy of the ventricle, with the septum most commonly involved. If the patient’s ECG and echocardiogram are normal, consideration could be given to pursuing an electrophysiological study. Until the results of the ECG and echocardiogram are available, the patient may not return to sports.