Exercise-related syncope in young competitive athletes without evidence of structural heart disease. Clinical presentation and long-term outcome

Aims Exercise-related syncopal spells in athletes receive great attention and are a source of anxiety in the sporting world. The aim of the present study is to describe the clinical presentation, the yield of the initial diagnostic work-up and the long-term outcome of a series of consecutive competitive athletes with recurrent exercise-related syncopal spells. Methods and Results The study cohort included 33 athletes (20 females, mean age 21·4±3·2 years) referred for recurrent unexplained episodes of exercise-related syncope (mean number of spells before evaluation 4·66±1·97). All athletes underwent an extensive evaluation, including echocardiography, 24-h electrocardiographic monitoring, exercise testing, cardiac electrophysiological study and head-up tilt testing. The echocardiographic examination revealed the presence of a mitral valve prolapse in two cases (6·0%). During maximal exercise testing, four athletes (12·1%) developed hypotension associated with pre-syncope. Twenty-two subjects (66·6%) showed a positive response to head-up tilt testing. During follow-up (33·5±17·2 months) 11/33 athletes (33·3%) showed at least one recurrence of exercise-related syncope (mean time to first recurrence 20·4±14·5 months). No other adverse event of any kind was noted during follow-up. The Kaplan–Meier estimates of first recurrence of exercise-related syncope after 12, 36 and 60 months were 9·1%, 24·4% and 42·9%. The number and frequency of exercise-related syncopal spells before evaluation were found to be univariate predictors of syncope recurrence (P