Working Diagnosis:
Orthostatic syncope/presyncope mediated by Bezold-Jarisch reflex.

Treatment:
The athlete was treated with initially with midodrine (alpha-1 receptor agonist) 10-15mg daily with exercise. The althlete's symptoms were improved and she resumed playing college soccer. However, the symptoms returned and there was no improvement with a titrated dose of midodrine.
Further cardiology recommendations were sought.

Outcome:
Cardiology recommended the athlete could safely participate in sports if she would rest immediately when she has any symptoms, and if she could play in an accident-free environment. However, after a meeting with the team physician and athletic trainer to discuss risks and her current limited ability to play, the athlete elected to discontinue participation in soccer for the year. There has been no recurrence of symptoms at rest. Patient met with a cardiac electrophysiologist, who agreed with the decision to withdraw from play at this time. It has been suggested that young individuals with this condition may "outgrow" it, and the athlete might consider trying to play soccer again in future seasons.

Author's Comments:
Conditions such as orthostatic syncope/presyncope mediated by Bezold-Jarisch reflex may be seen as a cause for exertional syncope and presyncope. Carotid sinus baroreceptors sense hypotension and trigger a sympathetic response secondary to blood pooling in the lower extremities and decreased intracardiac volume. The left ventricle is underfilled, and this leads to a paradoxical response with bradycardia, decreased cardiac contractility, and sudden hypotension.

Editor's Comments:
There are many potential causes for syncope and presyncope but episodes during exercise in an athlete are uncommon. A thorough evaluation is needed in order to rule out a potentially fatal condition. Nonetheless, most causes of exercise induced syncope are neurocardiogenic and are considered benign. Bethesda guidelines do not recommend restrictions on particiaption for athletes with neurocardiogenic causes of syncope. These guidelines as well as considerations for athlete safety can be very useful to the team physician when counseling an athlete with syncope or pre syncope during exercise.

References:
The 36th Bethesda Conference: eligibility recommendations for competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol 2005;45(8)1318-1382.

O'Connor FG, Oriscello RG, Levine BD: Exercise-related syncope in the young athlete: reassurance, restriction or referral? Am Fam Physician 1999;60(7):2001-2008

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