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August 1, 2017 Circulation. 2017;136:e60–e122. DOI: 10.1161/CIR.0000000000000499 e94

Recommendations for Athletes

COR LOE Recommendations

I C-EO Cardiovascular assessment by a care provider experienced in treating athletes with syncope is recommended prior to resuming competitive sports.

N/A A thorough history and physical examination should be completed by an experienced provider, including an assessment for OH and evidence of underlying cardiovascular disease.709–711 Cardiovascular causes account for 75% of sport-related deaths in young athletes.709,710 Syncope that occurs after exercise is often of benign origin and may be due to abdominal venous pooling. However, syncope during exercise is a much more compelling symptom and can be a harbinger of SCD.712,713 Syncopal episodes first require a personal and family history to evaluate precipitating causes and benign conditions, particularly volume depletion and vasovagal activity. Concomitant illnesses, especially viral infections, should be investigated and an ECG obtained.709,710 IIa C-LD Assessment by a specialist with disease-specific expertise is reasonable for athletes with syncope and high-risk markers.706,714

N/A Syncope in the competitive athlete requires an evaluation for potentially fatal causes of syncope, especially when evidence of HCM, LQTS, Wolff-Parkinson-White syndrome, ARVC, ventricular noncompaction, symptomatic mitral valve prolapse, Marfan syndrome, congenital coronary anomalies, or other at-risk conditions is present.706,709,715,716 Any suspected cardiovascular pathology requires further evaluation, and family counseling and/or genetic testing is advised for those conditions with a known familial tendency. IIa C-LD Extended monitoring can be beneficial for athletes with unexplained exertional syncope after an initial cardiovascular evaluation.717,718

N/A For those with a suspected cardiovascular etiology of syncope, an evaluation includes an ECG, tilt-table testing, and imaging as clinically indicated (Figure 3).719 Imaging may include echocardiography or MRI as required. Exercise stress testing, unless contraindicated, can be helpful. For persistent unexplained syncope, extended arrhythmia monitoring can be used, as appropriate. This is a rapidly evolving field, with no firm data on the best device and optimum monitoring period.720 III: Harm B-NR Participation in competitive sports is not recommended for athletes with syncope and phenotype-positive HCM, CPVT, LQTS1, or ARVC before evaluation by a specialist.704,721–724 See Online Data Supplement 42. In the absence of vagal mechanisms, VA in patients with HCM, CPVT, LQTS1, or ARVC is catecholamine sensitive. Participation in competitive sports in that circumstance in these patients is not recommended.704,715,716

11 QUALITY OF LIFE AND

HEALTHCARE COST OF SYNCOPE

11.1 Impact of Syncope on Quality

of Life

QoL is reduced with recurrent syncope,725–733 as demonstrated in studies that compared patients with and without syncope.727,731 QoL associated with recurrent syncope was equivalent to severe rheumatoid arthritis and chronic low-back pain in an adult population.728 Similarly, pediatric patients with recurrent syncope reported worse QoL than individuals with diabetes mellitus and equivalent QoL to individuals with asthma, end-stage renal disease, and structural heart disease.725 In a hospital-based cohort of patients with a prior episode of syncope, 33% reported syncope-related functional impairments with daily activities, such as driving or working.732 Those with more frequent syncope have reported poorer QoL.726,729,730,732 There is consistent evidence that syncope is associated with worse function on multiple domains of QoL, such as perceptions of low overall physical health725,730,734; perception of mental health, including increased fear, somatization, depression, and anxiety725,727,728,731,734; and impairment in activities of daily living, such as driving, working, and attending school. QoL impairments associated with syncope improve over time.733 In the Fainting Assessment Study,733 general and syncope-specific QoL improved over a 1-year period. Predictors of worse QoL over time include ad- vanced age, recurrent syncope, neurological or psychogenic reason for syncope, and greater comorbidity at baseline.733 Syncope-related QoL can be improved through effective diagnosis and treatment. In 1 study, use of an implantable loop recorder increased diagnostic rate, reduced syncope recurrence, and improved QoL as compared with patients who received a conventional diagnostic workup.164 In a second study, nonpharmacological treatment of recurrent syncope was associated with reductions in recurrent syncope and improvements in QoL.729

11.2 Healthcare Costs Associated

with Syncope

High healthcare costs are associated with the evaluation and management of syncope. Costs are defined as the resources needed to produce a set of services and are distinct from charges billed by facilities and healthcare providers.735 Most studies have focused on facility costs and excluded professional fees and patient copays. These high costs have been estimated both in the United States and abroad. In the US Healthcare Utilization Project, total annual hospital costs exceeded $4.1 billion in 2014 dollars, with a mean cost of $9400 per admission.736 Total costs and costs per admission for presumptive undiagnosed syncope were $1.6 billion and $7200, respectively.736 Single-center studies from multiple countries, including Austria, the United Kingdom, Israel, and Spain, confirm similarly high costs associated with the hospital evaluation of syncope.122,737,738

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