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| ''Roland D. Thijs, Robert H.A. Reijntjes, J. Gert van Dijk''<br/>
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| ''Department of Neurology and Clinical Neurophysiology, Leiden, The Netherlands''<br><br/>
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| {{case_present|
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| == Background ==
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| Exercise-related syncope without organic heart disease
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| has frequently been reported in young athletes [2, 5,
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| 9–11, 14]. The exact incidence of idiopathic exercise-related syncope among young athletes is not known.
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| Calkins et al. and Colivicchi et al. found that after a thorough cardiac evaluation athletes with an exertional-related syncope could safely continue to participate in athletics [2, 3]. Tilt-table testing may be a useful diagnostic
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| tool provoking syncope in 41 % of 24 athletes and up to
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| 79 % after isoproterenol infusion [5]. Idiopathic exercise-related syncope has been reported to result from
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| hypotension together with a normal HR, tachycardia,
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| bradycardia or asystole [2, 9]. The pathophysiology of
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| this condition is poorly understood [9]. Atenolol, hydrofludrocortisone, disopyramide, transdermal scopolamine and increased salt intake have been recommended as treatment for exercise-related syncope [2, 5,
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| 10, 11, 13]. To our knowledge this is the first report of a
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| beneficial effect of water drinking for this condition.
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|
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| == Case ==
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| A 20-year-old male pupil of a sporting school had
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| had attacks of lightheadedness over several months. The
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| first time he felt unsteady and fell to the ground when he
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| dismounted his bicycle after 1-hour of moderate exercise. In addition, he had chest pain and was short of
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| breath. He was not certain whether or not he had passed
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| out. Nobody had witnessed the event. For two hours afterwards he complained of unclear vision as if “looking
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| through salad oil”. He had not been incontinent, had
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| sustained no bruises and no tongue bite. Later, similar
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| attacks occurred during light cycling, after competition
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| skating, after skiing and during miction after exercise. He has a medical history of asthma and migraine. Both
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| a cardiologist and a pulmonologist had analyzed the
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| presenting complaints previously but could not find an
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| explanation. Previous examinations had consisted of an
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| ECG, echocardiography, bicycle stress testing, laboratory screen, chest X-ray and a lung perfusion scintigraphy. His medications were formoterol inhalations 12
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| mcg bid, budesonide inhalations 200 mcg bid and pantazol 20 mg od. The patient did not use coffee, nicotine
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| or drugs. On physical examination no abnormalities
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| were noted. The patient’s supine blood pressure (BP)
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| was 110/65 mmHg with a resting heart rate (HR) of 70
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| beats per minute (bpm). Neurological examination
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| showed slightly impaired fine motor skills and frequent
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| eye blinks either left or right sided.}}
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|
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| == Test results ==
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| A magnetic resonance imaging study of the brain was
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| normal. Test of HR and BP during rest (70 bpm;
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| 108/65 mmHg), deep breathing, standing up (85 bpm;
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| 121/91 mmHg),a Valsalva maneuver and sustained hand
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| grip were all normal. A tilt-table test (without medication) showed no abnormalities. Cathecholamine concentrations in plasma were obtained by venapuncture in
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| both supine and after 30 minutes upright position (norepinephrine(NE): 1.22 nmol/l vs. 3.67 nmol/l, epinephrine(E): 0.13 vs. 0.16 nmol/l, dopamine(DA): 0.04
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| vs. 0.07 nmol/l, respectively) and in 24-hour urine (NE:
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| 0.43 µmol, E: 0.06 µmol, DA: 2.46 µmol).
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| In view of the relation to exercise, the patient was
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| asked to mimic a typical bicycle tour on an ergometer,
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| while EEG, ECG and BP (Finapres, finger photoplethysmography) were continuously monitored. Cycling at
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| maximal effort increased HR up to 185 bpm (mean ±
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| standard deviation: 176 ± 7 bpm) without significant BP
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| changes (systolic BP (SBP) 119 ±14mmHg; diastolic BP
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| (DBP) 72 ±9 mmHg). Immediately after cessation of exercise BP fell to 75/45 mmHg, during which the patient
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| felt unsteady and complained of blurred vision; there
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| was no loss of consciousness. During the BP drop, electrocardiography revealed sinus tachycardia of 180 bpm.
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| The patient recognized the sensations as similar to those
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| of spontaneous attacks.
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|
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| == Treatment ==
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| A second exercise test was performed two weeks later, 15 minutes after rapid consumption of 1000 mL water. Symptoms did not recur at
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| the second test. Compared to the first cycling test the
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| maximal rise of HR during exercise was reduced to 155
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| bpm and the BP raised during exercise (SBP
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| 149 ± 21 mmHg; DBP 94 ± 14 mmHg). No significant BP
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| drop occurred after cycling. Fig. 1 displays the changes of heart rate and blood pressure during both tests. Furthermore exercise-related symptoms were succesfully
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| prevented by water ingestion. However, after 2 months
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| our patient complained of attacks during ordinary daily
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| activity. As these attacks could not be anticipated and
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| occurred frequently, we advised to stop the extra water
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| ingestion and precribed sodium tablets (7.2 g/day) instead. After 2 months he had had no complaints.
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|
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| == References ==
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|
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| <biblio>
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| #Bjornstad pmid=1782647
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| #Calkins pmid=7754948
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| #Colivicchi pmid=12090751
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| #Fleg pmid=3717041
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| #Grub pmid=1670907
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| #Holtzhausen pmid=8614313
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| #Jacob pmid=11018167
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| #Jordan pmid=10662747
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| #Kosinski2000 pmid=11225599
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| #Kosinski1996 pmid=8701911
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| #Sakaguchi pmid=7863992
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| #Shannon pmid=11904109
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| #Sneddon pmid=8043337
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| #Takase pmid=11195600
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| #Wolthuis pmid=830206
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| </biblio>
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