The Search for Syncope in

a Young Athlete
E. Harrison, MD
35 yo man generally very healthy
Active military at MacDill AFB
Runs approx 6 miles daily without problems
At about 4 miles into run on Bayshore he had sudden
sensation of being out of breath and was aware of being
slightly dizzy. His next memory is of picking himself up
off the ground
No characteristics of a seizure per bystanders
Never had an event like this in his life
Past Medical History
 Surgery on his arm after a dislocation
 No hypertension, DM, dyslipidemia
 Heart mumur as a child – no other cardiac issues
 Took malaria prophylaxis for work overseas

Social History
 Native of Detroit
 Never a smoker, no significant alcohol use
 Active duty in Air Force
 Married with one healthy child
Family History
 Father alive age 63 with DM, Prostate Cancer
 Mother alive age 59 with HTN
 Paternal Uncle and Grandfather with CAD
 Three sisters are all healthy

Review of Systems
 No active complaints
 No asthma or bronchitis
 No palpitations or chest pains
 Some loose stool recently but not excessive
 Remainder of systems negative
Physical Examination
 Afebrile, BP 130/80, HR 70, RR 16
 HEENT: small abrasion over right zygomatic
 NECK: normal carotids, no jvd, normal thyroid
 LUNGS: clear
 HEART: PMI normal, no murmur, regular, no heaves or lifts
 ABD: soft, non-tender
 EXT: good pedal pulses
 SKIN: warm and dry, no edema, no rashes
 NEURO: non-focal examination
Labs at initial evaluation
 Normal electrolytes
 Normal PT/PTT
 K+ 4.2, BUN 11
 Hgb 14, crit 42

Chest Film – normal

CT Head – right maxillary sinus thickening otherwise

normal
Baseline EKG
V/Q Scan – low probability for PE

Echocardiogram
 Normal ejection fraction
 Normal LV wall thickness
 No outflow tract obstruction
 Redundant mitral valve with no regurgitation

Tilt Table Testing – negative including isuprel

Neurologic Consultation
 EEG awake and asleep are normal
 MRI is normal
Signal Averaged ECG
Exercise Stress Test
Nuclear Perfusion Scan
Bayshore Protocol ETT
Left & Right Heart Cath
Hemodynamics
 Aorta 120/70
 LV 120/20
 RA Mean 10
 RV 28/10
 PA 24/12
 PCWP 14
 Cardiac output 6.7 (thermo), 4.68 (Fick)
 Ao Sat 97%, PA Sat 70% - Hgb 14.4
Left & Right Heart Cath
LV Gram in RAO
 Normal sized LV with normal contractility
 No mitral regurgitation
 No abnormalities of the aorta

Coronary Angiography
 RCA arises from the left coronary cusp beneath the left
main coronary. It supplied a long PDA and RV branches but
nothing to distal RCA and no evidence of an AV nodal
branch. This was supplied by the distal circumflex
 Normal left sided arteries
Post Bypass ETT
Coronary Anomalies
Coronary Anomalies
Congenital anomalies not uncommonly associated with
SCD in athletes

Although relatively rare, events are often catastrophic

and likely provoked by myocardial ischemia

Rarely discovered during life often due to lack of

clinical suspicion

Amenable to surgical treatment, therefore timely

identification is critical
 Coronary Anomalies
Standard testing with ECG at rest or stress is unlikely to
provide evidence of ischemia and thus not reliable as
screening tests in large athletic populations

Premonitory cardiac symptoms not uncommonly occur

shortly before sudden death

This suggest that exertional syncope or chest pain

requires exclusion of this anomaly

J Am Coll Cardiol 2000;35:1493-501

Coronary Anomalies