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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Sudden transient loss of consciousness during exercise, especially unaccustomed exercise, with rapid spontaneous recovery

  • Absence of prodromal symptoms

  • History of heart disease, heart murmurs, or other cardiac symptoms

GENERAL CONSIDERATIONS

  • Usually secondary to a hemodynamic abnormality

  • Stenotic valvular heart disease and left ventricular outflow tract abnormality are the most frequent hemodynamic causes

  • Exercised-induced ventricular tachycardia (VT) is uncommon

  • Catecholaminergic polymorphic VT (CPVT) is a genetic condition that occurs in the presence of no structural heart disease. In the right clinical context, CPVT should also be considered

  • Intracardiac tumors such as atrial myxoma are a rare cause of effort syncope

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Effort syncope

  • Dyspnea may be present in patients with significant valvular heart disease

  • Chest pain in some patients

PHYSICAL EXAM FINDINGS

  • Depends on the underlying cause

  • Auscultation:

    • – Systolic ejection murmur in aortic stenosis and hypertrophic cardiomyopathy, the most common causes

    • Tumor plop during early diastole in left atrial myxoma

  • Clinical examination may be normal if the precipitating cause is an arrhythmia or ischemia

DIFFERENTIAL DIAGNOSIS

  • Severe aortic stenosis

  • Hypertrophic obstructive cardiomyopathy

  • Discrete subaortic stenosis or supravalvular aortic stenosis

  • Severe mitral stenosis

  • Severe pulmonic stenosis

  • Severe pulmonary hypertension

  • Intracardiac tumors

  • Arrhythmia-induced syncope

  • Transient myocardial ischemia

  • Severe left ventricular dysfunction

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC, basic metabolic panel

ELECTROCARDIOGRAPHY

  • ECG: abnormality noted depends on the underlying cause

  • Exercise treadmill ECG in patients with structurally normal heart and effort syncope to identify arrhythmogenic causes

IMAGING STUDIES

  • Echocardiogram to identify and quantify valvular heart disease, myocardial disease, cardiac tumor, and left ventricular function

DIAGNOSTIC PROCEDURES

  • Coronary angiogram if transient severe ischemia is the leading suspicion for the effort syncope

  • Rarely, electrophysiologic studies may be required (generally not very helpful)

TREATMENT

CARDIOLOGY REFERRAL

  • All patients should be evaluated by a cardiologist

HOSPITALIZATION CRITERIA

  • Most patients require an in-hospital evaluation unless an echocardiogram is completely normal

MEDICATIONS

  • Treat the underlying condition

  • Avoid unaccustomed exertion

THERAPEUTIC PROCEDURES

  • Depends on the underlying cause

SURGERY

  • Depends on the underlying cause

MONITORING

  • Depends on the underlying cause

DIET AND ACTIVITY

  • Depends on the underlying cause

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • After adequate treatment of underlying cause

FOLLOW-UP
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