Working Diagnosis:
Symptomatic hypotension during cardiac stress test with abnormal tilt table test suggestive of postural orthostatic tachycardia syndrome (POTS)

Treatment:
The athlete was held from physical activity upon discharge from the Emergency Department and for about 3 months as his evaluation was completed. As the work-up revealed no structural cardiac abnormality and the patient reported no repeat events, he was cleared for a gradual return to play with attention to adequate hydration and symptom monitoring with his athletic trainer.

Outcome:
The athlete underwent a gradual return to play progression starting with participation in pre-game warm-ups, then advancing to practice at half-maximum effort, with the goal of competitive play in 2 to 4 weeks

Author's Comments:
In a young, healthy athlete with near-syncope, chest pain and shortness of breath, a broad investigation is warranted to investigate the underlying etiology. This is especially true in an African American, male, collegiate basketball player with a family history of heart disease, a population that is at particularly high risk of sudden cardiac death. A tilt table test can be helpful in evaluating syncope of unknown cause. An increase in heart rate of greater than 30 beats per minute or an increase to 120 beats per minute or greater within the first 10 minutes of the passive phase of the test, without a decrease in blood pressure, is diagnostic for POTS in adults. Exercise is a hallmark of therapy in POTS patients, with symptoms potentially worsened by deconditioning. There is limited research on return to play guidelines in POTS patients.

Editor's Comments:
The results of tilt-table testing should be considered with caution, particularly in athletes. Is it important to note that in this case, the athlete underwent extensive testing to evaluate for structural and electrical cardiac causes for his symptoms before being recommended for tilt-table testing. In patients with unexplained syncope, the positivity rate of tilt-table testing is 50-75 percent, with a false-positive rate of 7-65 percent. In athletes however, the positivity rate may approach 100 percent. Reproducibility of the test is also variable, with 10-93 percent of patients with unexplained syncope and a negative test having a positive test when it is repeated. For these reasons, tilt-table testing should not be used as the primary basis for diagnosis of unexplained syncope in an athlete.

References:
Bryarly M, Phillips LT, Fu Q, Vernino S, Levine BD. Postural Orthostatic Tachycardia Syndrome: JACC Focus Seminar. J Am Coll Cardiol. 2019 Mar 19;73(10):1207-1228.

Freeman, R., Wieling, W., Axelrod, F.B. et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res 21, 69–72 (2011).

Harmon KG, Asif IM, Maleszewski JJ, Owens DS, Prutkin JM, Salerno JC, Zigman ML, Ellenbogen R, Rao AL, Ackerman MJ, Drezner JA. Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review. Circulation. 2015 Jul 7;132(1):10-9.

Hastings JL, Levine BD. Syncope in the athletic patient. Prog Cardiovasc Dis. 2012 Mar-Apr;54(5):438-44.

Bryarly M, Phillips LT, Fu Q, Vernino S, Levine BD. Postural Orthostatic Tachycardia Syndrome: JACC Focus Seminar. J Am Coll Cardiol. 2019 Mar 19;73(10):1207-1228.

Freeman, R., Wieling, W., Axelrod, F.B. et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res 21, 69–72 (2011).

Harmon KG, Asif IM, Maleszewski JJ, Owens DS, Prutkin JM, Salerno JC, Zigman ML, Ellenbogen R, Rao AL, Ackerman MJ, Drezner JA. Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review. Circulation. 2015 Jul 7;132(1):10-9.

Hastings JL, Levine BD. Syncope in the athletic patient. Prog Cardiovasc Dis. 2012 Mar-Apr;54(5):438-44

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