CASE REPORT

In March 2002, a 25 year old white woman presented to the British Olympic Medical Centre after bouts of syncope and pre-syncope. The athlete was an international rower, competing in the single sculls event, and was training an average of 10 sessions/week. Training sessions included rowing and weight training, with training across the full range of intensities. The presenting symptoms included two episodes of syncope after 2000 m maximal tests on a rowing ergometer, together with episodes of pre-syncope on water that had not resulted in syncope. All episodes of pre-syncope/syncope occurred immediately after exercise in a seated position. The duration of syncope was not formally documented but was described as lasting one or two minutes, with periods of malaise lasting for considerable periods (more than one hour) after syncope. There had been no previous examination of heart rate and/or blood pressure response during these episodes. Separately the patient noted a tendency for pre-syncope and syncope during medical procedures. There was no family history of heart disease including sudden “unexplained” death.

On examination, the athlete was in sinus rhythm with bradycardia (about 40 beats/min) and sinus arrhythmia. All other measures, including PR and QT interval, were within normal limits. Resting blood pressure was 110/70 mm Hg. Echocardiography showed normal intracardiac dimensions (maximum left ventricular wall thickness; 10 mm) with normal systolic function of both left and right ventricles. Origins of left and right coronary arteries were normal. Mild pulmonary valve regurgitation was noted (inaudible clinically).

During integrated cardiopulmonary exercise stress testing, the athlete completed level 5 of a BRUCE protocol stopping because of maximal exercise capacity. …