Exertional Syncope in Athletic Middle Aged Males Without Angina: Consider Ischaemic Ventricular Tachycardia

Abstract

Reduced classical ischaemic symptoms in athletic middle aged males may mask critical ischaemia. Critical ischaemia triggering ventricular arrhythmias presenting as syncope may be the first ischaemic presentation. We describe three athletic middle-aged males who presented with exertional syncope. All 3 denied frank classical ischaemic exertional symptoms and had above normal exertional tolerances. Routine non invasive cardiac investigations were normal, with their exercise tolerances above 10 METS. Ventricular tachycardia (VT) was demonstrated at electrophysiological study or on loop recorder tracings. Coronary angiography revealed critical single vessel coronary stenosis that were successfully revascularised by percutaneous coronary intervention (PCI). Post PCI, no further arrhythmias or syncope have occurred, In retrospect, all 3 report a minor decline in exercise tolerance, that had been attributed to ageing, had resolved post PCI. Possible contributors include a lack of cardiac awareness, ischaemic preconditioning, “pushing through’ minor initial exertional symptoms, attribution of minor symptoms to ageing or a combination of the above. Clinicians should maintain a high index of suspicion that exertional syncope in athletic middle aged males without angina may unmask critical ischaemia. This ischaemia may trigger VT, and direct coronary imaging with CTCA or angiography and appropriate revascularisation are needed.