Young Athlete with Exertional Syncope and Family History
A 16-year-old male basketball player presents for a preparticipation evaluation. He reports two episodes of syncope during practice in the past year, both occurring during sprint drills. He denies chest pain, palpitations, or shortness of breath. He has no chronic medical conditions and takes no medications. His father died suddenly at age 45, and a paternal uncle had a heart transplant at age 40. On exam: BP 118/72, HR 68, normal cardiac exam, no murmurs. He is tall and thin with a marfanoid habitus. His ECG shows a shortened PR interval, a delta wave, and a widened QRS. He is eager to play and says he feels fine.
1. What is the most likely diagnosis and what further evaluation is needed?
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The most likely diagnosis is Wolff-Parkinson-White (WPW) syndrome, given the ECG findings of a short PR interval, delta wave, and wide QRS. However, the history of exertional syncope and family history of sudden death raises concern for a channelopathy or cardiomyopathy. The marfanoid habitus also raises the possibility of Marfan syndrome with aortic root disease. Further evaluation: refer to pediatric cardiology for echocardiogram, exercise stress test, and possibly genetic testing. WPW can be associated with sudden cardiac death, especially if there is a history of syncope. The family history of sudden death at age 45 and heart transplant suggests a possible inherited cardiac condition. Until cleared, he should be restricted from competitive sports.
2. What are the return-to-play considerations for this athlete?
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Return to play depends on the underlying diagnosis. For WPW, if the accessory pathway is found to be high-risk (short effective refractory period), catheter ablation may be recommended. After successful ablation and clearance by cardiology, he may return to play. If a cardiomyopathy or channelopathy is diagnosed, restriction may be lifelong. The family history warrants screening of first-degree relatives. The athlete should not participate until a complete evaluation is done. Shared decision-making with the family and cardiology is essential.