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 occurred frequently, we advised to stop the extra water
 ingestion and precribed sodium tablets (7.2 g/day) instead. After 2 months he had had no complaints.
+== Discussion ==
+Our patient had symptoms and signs of exercise-related
+(pre)-syncope. Despite extensive investigations we
+could not identify a certain cause for this disorder of
+cardiovascular regulation.
+Our patient had compared to healthy men a low exertional BP<cite>Wolthuis</cite> and compared to healthy endurance
+trained men a relatively high resting HR.<cite>Bjornstad</cite> The cardiovascular changes of our patient seem similar to those
+seen in patients with postural orthostatic tachycardia
+syndrome (POTS) while standing.<cite>Jacob</cite> Supposing that exercise poses a larger workload to the cardiovascular system compared to standing, one could argue that our patient has a mild variant of POTS.
+We hypothesized that our patient’s symptoms were
+primarily related to failure of sympathetic vasoconstriction. Therefore, we examined the effect of water drinking, as water drinking has been demonstrated to rapidly
+raise sympathetic activity.<cite>Jordan</cite>
+Water drinking has been described previously by
+Shannon et al. as a treatment for orthostatic and postprandial hypotension in patients with autonomic failure
+and orthostatic tachycardia in patients with orthostatic
+intolerance.Water drinking (480 mL) raises plasma norepinephrine levels as much as classic sympathetic stimuli as caffeine and nicotine.<cite>Jordan</cite> The pressor effect of water in patients and older controls reached a maximum
+after 30 minutes and lasted over 60 minutes. In our case
+we chose to use 1000 mL tap water instead of 480 mL, as
+the pressor effect of 480 mL tap water was not present in
+healthy young subjects compared to older controls.
+Moreover, as exercise induces a decrease of plasma volume<cite>Holtzhausen</cite> a larger volume is needed.
+As the symptoms of post-exercise hypotension result
+from an only brief failure of cardiovascular regulation, a
+short lasting therapy is preferable. Besides this, symptom relief should outweigh any possible side effect. In
+contrast to previously recommended medications,water
+drinking has both a short lasting effect and few side effects. Therefore we suggest water drinking as a simple
+and possible effective therapy for idiopathic exercise-related syncope.
 == References ==