Exertional Syncope In A Athlete With Recent SARS-Cov-2 Infection - Endurance Sport

Abstract

HISTORY: A 53-year-old competitive masters endurance athlete presented for return to sport clearance following SARS-CoV-2 infection (mild symptoms lasting 3-14 days, including nose & throat symptoms, cough, fever, and myalgia). There was a history of episodes of intermittent exertional light-headedness, chest pain, shortness of breath, and syncope for the past 10 years, precipitated by sudden cessation of running and lasting <30 seconds. The patient had no significant past medical history nor risk factors for coronary heart disease. PHYSICAL EXAMINATION: Vital signs were normal. No symptoms on orthostatic testing. Cardiovascular examination revealed an inferiorly displaced apex beat, normal heart sounds, no evidence of a murmur with dynamic movements, no pericardial rub nor pedal oedema. Distal pulses were equal with a normal rhythm, no radio-femoral delay. Respiratory, neurological, abdominal, and otolaryngological examinations were normal. DIFFERENTIAL DIAGNOSIS: 1. Coronary artery disease 2. Exercise associated postural hypotension 3. Cardiac arrhythmia 4. Valvular heart disease (aortic stenosis) 5. Viral myopericarditis 6. Cardiomyopathy 7. Autonomic dysfunction TEST AND RESULTS: Blood results: FBC = normal CRP < 1 mg/L Creatinine kinase = 153 U/L Troponin-T = 7 ng/L. Lung function tests: FEV1/FVC = 108% predicted. Resting ECG: LA enlargement. T-wave inversion in inferior and precordial leads (V2-V6). Stress ECG: Upsloping ST-segment depression in V4 + V5 during exercise, changing to downsloping during recovery. Normal BP and HR response to exercise and recovery. Echocardiogram: Normal except mild mitral regurgitation. Cardiac MRI: Normal heart size. Marked asymmetric thickening of the apex with cavity obliteration during systole. Marked late gadolinium enhancement with near transmural enhancement of the apex with patchy enhancement extending to the hypertrophied area. No epicardial enhancement noted FINAL WORKING DIAGNOSIS: Apical hypertrophic cardiomyopathy TREATMENT AND OUTCOMES: 1. Referred to a specialist cardiologist for 72-hour Holter ECG monitoring. 2. No arrhythmias (rest and exercise) detected. 3. Following extensive counselling by the physician and ensuring comprehension, the patient decided against further testing and wanted to continue with regular exercise.