Electrophysiological Approach to Syncope and Near-Syncope in the Athlete

  • Rakesh Gopinathannair
  • Brian Olshansky


A 20-year-old male college basketball player passes out 2 min after finishing a training session. He recovers consciousness in a few seconds without confusion, nausea, or vomiting but does not remember anything that happened.


Ventricular Tachycardia Catheter Ablation Hypertrophic Cardiomyopathy Structural Heart Disease Accessory Pathway 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Estes NA III, Link MS, Cannom D, et al. Report of the NASPE policy conference on arrhythmias and the athlete. J Cardiovasc Electrophysiol. 2001;12(10):1208–1219.PubMedCrossRefGoogle Scholar
  2. 2.
    Maron BJ, Zipes DP. Introduction: Eligibility recommendations for competitive athletes with cardiovascular abnormalities-general considerations. J Am Coll Cardiol. 2005;45(8):1318–1321. 10.1016/j.jacc.2005.02.006.PubMedCrossRefGoogle Scholar
  3. 3.
    Zipes DP, Ackerman MJ, Estes NA III, Grant AO, Myerburg RJ, Van Hare G. Task force 7: Arrhythmias. J Am Coll Cardiol. 2005;45(8):1354–1363. 10.1016/j.jacc.2005.02.014.PubMedCrossRefGoogle Scholar
  4. 4.
    Maron BJ, Roberts WC, McAllister HA, Rosing DR, Epstein SE. Sudden death in young athletes. Circulation. 1980;62(2):218–229.PubMedCrossRefGoogle Scholar
  5. 5.
    Kramer MR, Drori Y, Lev B. Sudden death in young soldiers. high incidence of syncope prior to death. Chest. 1988;93(2):345–347.PubMedCrossRefGoogle Scholar
  6. 6.
    Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope. N Engl J Med. 2002;347(12):878–885. 10.1056/NEJMoa012407.PubMedCrossRefGoogle Scholar
  7. 7.
    Kapoor WN, Hanusa BH. Is syncope a risk factor for poor outcomes? comparison of patients with and without syncope. Am J Med. 1996;100(6):646–655.PubMedCrossRefGoogle Scholar
  8. 8.
    Martin TP, Hanusa BH, Kapoor WN. Risk stratification of patients with syncope. Ann Emerg Med. 1997;29(4):459–466.PubMedCrossRefGoogle Scholar
  9. 9.
    Olshansky B, Hahn EA, Hartz VL, Prater SP, Mason JW. Clinical significance of syncope in the electrophysiologic study versus electrocardiographic monitoring (ESVEM) trial. The ESVEM investigators. Am Heart J. 1999;137(5):878–886.PubMedCrossRefGoogle Scholar
  10. 10.
    Turrini P, Corrado D, Basso C, Nava A, Thiene G. Noninvasive risk stratification in arrhythmogenic right ventricular cardiomyopathy. Ann Noninvasive Electrocardiol. 2003;8(2):161–169.PubMedCrossRefGoogle Scholar
  11. 11.
    Brugada R, Hong K, Cordeiro JM, Dumaine R. Short QT syndrome. CMAJ. 2005;173(11):1349–1354. 10.1503/cmaj.050596.PubMedCrossRefGoogle Scholar
  12. 12.
    Vohra J. The long QT syndrome. Heart Lung Circ. 2007;16(Suppl 3):S5–S12. 10.1016/j.hlc.2007.05.008.PubMedCrossRefGoogle Scholar
  13. 13.
    Antzelevitch C. Brugada syndrome. Pacing Clin Electrophysiol. 2006;29(10):1130–1159. 10.1111/j.1540–8159.2006.00507.x.PubMedCrossRefGoogle Scholar
  14. 14.
    Behr ER, Elliott P, McKenna WJ. Role of invasive EP testing in the evaluation and management of hypertrophic cardiomyopathy. Card Electrophysiol Rev. 2002;6(4):482–486.PubMedCrossRefGoogle Scholar
  15. 15.
    Olshansky B, Poole JE, Johnson G, et al. Syncope predicts the outcome of cardiomyopathy patients: Analysis of the SCD-HeFT study. J Am Coll Cardiol. 2008;51(13):1277–1282. 10.1016/j.jacc.2007.11.065.PubMedCrossRefGoogle Scholar
  16. 16.
    Goldenberg I, Moss AJ. Long QT syndrome. J Am Coll Cardiol. 2008;51(24):2291–2300. 10.1016/j.jacc.2008.02.068.PubMedCrossRefGoogle Scholar
  17. 17.
    Colivicchi F, Ammirati F, Santini M. Epidemiology and prognostic implications of syncope in young competing athletes. Eur Heart J. 2004;25(19):1749–1753. 10.1016/j.ehj.2004.07.011.PubMedCrossRefGoogle Scholar
  18. 18.
    Colivicchi F, Ammirati F, Biffi A, Verdile L, Pelliccia A, Santini M. Exercise-related syncope in young competitive athletes without evidence of structural heart disease. Clinical presentation and long-term outcome. Eur Heart J. 2002;23(14):1125–1130.PubMedCrossRefGoogle Scholar
  19. 19.
    Kapoor WN. Workup and management of patients with syncope. Med Clin North Am. 1995;79(5):1153–1170.PubMedGoogle Scholar
  20. 20.
    Maron BJ. Sudden death in young athletes. N Engl J Med. 2003;349(11):1064–1075. 10.1056/NEJMra022783.PubMedCrossRefGoogle Scholar
  21. 21.
    Burke AP, Farb A, Virmani R. Causes of sudden death in athletes. Cardiol Clin. 1992;10(2):303–317.PubMedGoogle Scholar
  22. 22.
    Samenuk D, Link MS, Homoud MK, et al. Adverse cardiovascular events temporally associated with ma huang, an herbal source of ephedrine. Mayo Clin Proc. 2002;77(1):12–16.PubMedCrossRefGoogle Scholar
  23. 23.
    Ramotar J. Cyclists’ deaths linked to erythropoietin? Phys Sportsmed. 1990;18:48.Google Scholar
  24. 24.
    Nasir JM, Durning SJ, Ferguson M, Barold HS, Haigney MC. Exercise-induced syncope associated with QT prolongation and ephedra-free xenadrine. Mayo Clin Proc. 2004;79(8):1059–1062.PubMedCrossRefGoogle Scholar
  25. 25.
    Somers VK, Abboud FM. Neurocardiogenic syncope. Adv Intern Med. 1996;41:399–435.PubMedGoogle Scholar
  26. 26.
    Manganelli F, Betocchi S, Ciampi Q, et al. Comparison of hemodynamic adaptation to orthostatic stress in patients with hypertrophic cardiomyopathy with or without syncope and in vasovagal syncope. Am J Cardiol. 2002;89(12):1405–1410.PubMedCrossRefGoogle Scholar
  27. 27.
    Kumpf M, Sieverding L, Gass M, Kaulitz R, Ziemer G, Hofbeck M. Anomalous origin of left coronary artery in young athletes with syncope. BMJ. 2006;332(7550):1139–1141. 10.1136/bmj.332.7550.1139.PubMedCrossRefGoogle Scholar
  28. 28.
    Corrado D, Thiene G, Cocco P, Frescura C. Non-atherosclerotic coronary artery disease and sudden death in the young. Br Heart J. 1992;68(6):601–607.PubMedCrossRefGoogle Scholar
  29. 29.
    Futterman LG, Myerburg R. Sudden death in athletes: An update. Sports Med. 1998;26(5):335–350.PubMedCrossRefGoogle Scholar
  30. 30.
    Michaud GF, Wang PJ, Estes NAM. Syncope in the athlete. In: Estes NAM, Salem DN, Wang PJ, eds. Sudden Cardiac Death in the Athlete. Armonk, NY: Futura, 1998:419–440.Google Scholar
  31. 31.
    Alboni P, Brignole M, Menozzi C, et al. Diagnostic value of history in patients with syncope with or without heart disease. J Am Coll Cardiol. 2001;37(7):1921–1928.PubMedCrossRefGoogle Scholar
  32. 32.
    Link MS, Wang PJ, Estes NA, III. Ventricular arrhythmias in the athlete. Curr Opin Cardiol. 2001;16(1):30–39.PubMedCrossRefGoogle Scholar
  33. 33.
    Oh JH, Hanusa BH, Kapoor WN. Do symptoms predict cardiac arrhythmias and mortality in patients with syncope? Arch Intern Med. 1999;159(4):375–380.PubMedCrossRefGoogle Scholar
  34. 34.
    Linzer M, Yang EH, Estes NA III, Wang P, Vorperian VR, Kapoor WN. Diagnosing syncope. part 1: Value of history, physical examination, and electrocardiography. clinical efficacy assessment project of the american college of physicians. Ann Intern Med. 1997;126(12):989–996.PubMedGoogle Scholar
  35. 35.
    Pelliccia A, Maron BJ, Culasso F, et al. Clinical significance of abnormal electrocardiographic patterns in trained athletes. Circulation. 2000;102(3):278–284.PubMedCrossRefGoogle Scholar
  36. 36.
    Reiffel JA, Schwarzberg R, Murry M. Comparison of autotriggered memory loop recorders versus standard loop recorders versus 24-hour holter monitors for arrhythmia detection. Am J Cardiol. 2005;95(9):1055–1059. 10.1016/j.amjcard.2005.01.025.PubMedCrossRefGoogle Scholar
  37. 37.
    Rothman SA, Laughlin JC, Seltzer J, et al. The diagnosis of cardiac arrhythmias: A prospective multi-center randomized study comparing mobile cardiac outpatient telemetry versus standard loop event monitoring. J Cardiovasc Electrophysiol. 2007;18(3):241–247.PubMedCrossRefGoogle Scholar
  38. 38.
    Brignole M, Sutton R, Menozzi C, et al. Early application of an implantable loop recorder allows effective specific therapy in patients with recurrent suspected neurally mediated syncope. Eur Heart J. 2006;27(9):1085–1092. 10.1093/eurheartj/ehi842.PubMedCrossRefGoogle Scholar
  39. 39.
    Krahn AD, Klein GJ, Yee R, Manda V. The high cost of syncope: Cost implications of a new insertable loop recorder in the investigation of recurrent syncope. Am Heart J. 1999;137(5):870–877.PubMedCrossRefGoogle Scholar
  40. 40.
    Maron BJ, Pelliccia A, Spirito P. Cardiac disease in young trained athletes. Insights into methods for distinguishing athlete’s heart from structural heart disease, with particular emphasis on hypertrophic cardiomyopathy. Circulation. 1995;91(5):1596–1601.PubMedCrossRefGoogle Scholar
  41. 41.
    Pelliccia A, Maron BJ, Spataro A, Proschan MA, Spirito P. The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes. N Engl J Med. 1991;324(5):295–301.PubMedCrossRefGoogle Scholar
  42. 42.
    Maron BJ. Structural features of the athlete heart as defined by echocardiography. J Am Coll Cardiol. 1986;7(1):190–203.PubMedCrossRefGoogle Scholar
  43. 43.
    Goldschlager N, Epstein AE, Grubb BP, et al. Etiologic considerations in the patient with syncope and an apparently normal heart. Arch Intern Med. 2003;163(2):151–162.PubMedCrossRefGoogle Scholar
  44. 44.
    Pelliccia A, Maron BJ, De Luca R, Di Paolo FM, Spataro A, Culasso F. Remodeling of left ventricular hypertrophy in elite athletes after long-term deconditioning. Circulation. 2002;105(8):944–949.PubMedCrossRefGoogle Scholar
  45. 45.
    Brignole M, Alboni P, Benditt D, et al. Guidelines on management (diagnosis and treatment) of syncope. Eur Heart J. 2001;22(15):1256–1306. 10.1053/euhj.2001.2739.PubMedCrossRefGoogle Scholar
  46. 46.
    Grubb BP. Neurocardiogenic syncope. In: Grubb BP, Olshansky B, eds. Syncope: Mechanisms and Management. Armonk, NY: Futura, 1998:73–106.Google Scholar
  47. 47.
    Grubb BP, Temesy-Armos PN, Samoil D, Wolfe DA, Hahn H, Elliott L. Tilt table testing in the evaluation and management of athletes with recurrent exercise-induced syncope. Med Sci Sports Exerc. 1993;25(1):24–28.PubMedCrossRefGoogle Scholar
  48. 48.
    Antzelevitch C. The brugada syndrome. J Cardiovasc Electrophysiol. 1998;9(5):513–516.PubMedCrossRefGoogle Scholar
  49. 49.
    Priori SG, Schwartz PJ, Napolitano C, et al. Risk stratification in the long-QT syndrome. N Engl J Med. 2003;348(19):1866–1874. 10.1056/NEJMoa022147.PubMedCrossRefGoogle Scholar
  50. 50.
    Brilakis ES, Shen WK, Hammill SC, et al. Role of programmed ventricular stimulation and implantable cardioverter defibrillators in patients with idiopathic dilated cardiomyopathy and syncope. Pacing Clin Electrophysiol. 2001;24(11):1623–1630.PubMedCrossRefGoogle Scholar
  51. 51.
    Bigger JT Jr, Reiffel JA, Livelli FD Jr, Wang PJ. Sensitivity, specificity, and reproducibility of programmed ventricular stimulation. Circulation. 1986;73(2 Pt 2):II73–II78.PubMedGoogle Scholar
  52. 52.
    Brugada P, Green M, Abdollah H, Wellens HJ. Significance of ventricular arrhythmias initiated by programmed ventricular stimulation: The importance of the type of ventricular arrhythmia induced and the number of premature stimuli required. Circulation. 1984;69(1):87–92.PubMedCrossRefGoogle Scholar
  53. 53.
    Peters S, Reil GH. Risk factors of cardiac arrest in arrhythmogenic right ventricular dysplasia. Eur Heart J. 1995;16(1):77–80.PubMedCrossRefGoogle Scholar
  54. 54.
    Brignole M, Menozzi C, Moya A, et al. Mechanism of syncope in patients with bundle branch block and negative electrophysiological test. Circulation. 2001;104(17):2045–2050.PubMedCrossRefGoogle Scholar
  55. 55.
    Menozzi C, Brignole M, Garcia-Civera R, et al. Mechanism of syncope in patients with heart disease and negative electrophysiologic test. Circulation. 2002;105(23):2741–2745.PubMedCrossRefGoogle Scholar
  56. 56.
    Jackman WM, Wang XZ, Friday KJ, et al. Catheter ablation of accessory atrioventricular pathways (wolff-parkinson-white syndrome) by radiofrequency current. N Engl J Med. 1991;324(23):1605–1611.PubMedCrossRefGoogle Scholar
  57. 57.
    Zardini M, Yee R, Thakur RK, Klein GJ. Risk of sudden arrhythmic death in the wolff-parkinson-white syndrome: Current perspectives. Pacing Clin Electrophysiol. 1994;17(5 Pt 1):966–975.PubMedCrossRefGoogle Scholar
  58. 58.
    Link MS, Homoud MK, Wang PJ, Estes NA III. Cardiac arrhythmias in the athlete. Cardiol Rev. 2001;9(1):21–30.PubMedCrossRefGoogle Scholar
  59. 59.
    Pappone C, Santinelli V, Manguso F, et al. A randomized study of prophylactic catheter ablation in asymptomatic patients with the wolff-parkinson-white syndrome. N Engl J Med. 2003;349(19):1803–1811. 10.1056/NEJMoa035345.PubMedCrossRefGoogle Scholar
  60. 60.
    Link MS, Estes NAM. Ventricular arrhythmias. In: Estes NAM, Salem DN, Wang PJ, eds. Sudden Cardiac Death in the Athlete. Armonk. NY: Futura, 1998:253–275.Google Scholar
  61. 61.
    Krediet CT, van Dijk N, Linzer M, van Lieshout JJ, Wieling W. Management of vasovagal syncope: Controlling or aborting faints by leg crossing and muscle tensing. Circulation. 2002;106(13):1684–1689.PubMedCrossRefGoogle Scholar
  62. 62.
    Jordan J, Shannon JR, Black BK, et al. The pressor response to water drinking in humans: A sympathetic reflex? Circulation. 2000;101(5):504–509.PubMedCrossRefGoogle Scholar
  63. 63.
    El-Sayed H, Hainsworth R. Salt supplement increases plasma volume and orthostatic tolerance in patients with unexplained syncope. Heart. 1996;75(2):134–140.PubMedCrossRefGoogle Scholar
  64. 64.
    Reybrouck T, Heidbuchel H, Van De Werf F, Ector H. Long-term follow-up results of tilt training therapy in patients with recurrent neurocardiogenic syncope. Pacing Clin Electrophysiol. 2002;25(10):1441–1446.PubMedCrossRefGoogle Scholar
  65. 65.
    Link MS, Homoud MK, Wang PJ, Estes NA III. Cardiac arrhythmias in the athlete: The evolving role of electrophysiology. Curr Sports Med Rep. 2002;1(2):75–85.PubMedGoogle Scholar
  66. 66.
    Haissaguerre M, Jais P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339(10):659–666.PubMedCrossRefGoogle Scholar
  67. 67.
    Calkins H, Kalbfleisch SJ, el-Atassi R, Langberg JJ, Morady F. Relation between efficacy of radiofrequency catheter ablation and site of origin of idiopathic ventricular tachycardia. Am J Cardiol. 1993;71(10):827–833.PubMedCrossRefGoogle Scholar
  68. 68.
    Klein LS, Miles WM. Ablative therapy for ventricular arrhythmias. Prog Cardiovasc Dis. 1995;37(4):225–242.PubMedCrossRefGoogle Scholar
  69. 69.
    Eisenberg SJ, Scheinman MM, Dullet NK, et al. Sudden cardiac death and polymorphous ventricular tachycardia in patients with normal QT intervals and normal systolic cardiac function. Am J Cardiol. 1995;75(10):687–692.PubMedCrossRefGoogle Scholar
  70. 70.
    European Heart Rhythm Association, Heart Rhythm Society, Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: A report of the american college of Cardiology/American heart association task force and the european society of cardiology committee for practice guidelines (writing committee to develop guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death). J Am Coll Cardiol. 2006;48(5):e247–e346. 10.1016/j.jacc.2006.07.010.Google Scholar
  71. 71.
    Lampert R, Cannom D, Olshansky B. Safety of sports participation in patients with implantable cardioverter defibrillators: A survey of heart rhythm society members. J Cardiovasc Electrophysiol. 2006;17(1):11–15.PubMedCrossRefGoogle Scholar
  72. 72.
    Schwartz PJ, Priori SG, Spazzolini C, et al. Genotype-phenotype correlation in the long-QT syndrome: Gene-specific triggers for life-threatening arrhythmias. Circulation. 2001;103(1):89–95.PubMedCrossRefGoogle Scholar
  73. 73.
    Moss AJ, Robinson JL, Gessman L, et al. Comparison of clinical and genetic variables of cardiac events associated with loud noise versus swimming among subjects with the long QT syndrome. Am J Cardiol. 1999;84(8):876–879.PubMedCrossRefGoogle Scholar
  74. 74.
    Priori SG, Napolitano C, Tiso N, et al. Mutations in the cardiac ryanodine receptor gene (hRyR2) underlie catecholaminergic polymorphic ventricular tachycardia. Circulation. 2001;103(2):196–200.PubMedCrossRefGoogle Scholar
  75. 75.
    Wilde AA, Bhuiyan ZA, Crotti L, et al. Left cardiac sympathetic denervation for catecholaminergic polymorphic ventricular tachycardia. N Engl J Med. 2008;358(19):2024–2029. 10.1056/NEJMoa0708006.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Division of Cardiology, Section of ElectrophysiologyUniversity of Louisville HospitalsLouisvillerUSA

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