Preparticipation Syncope and a Murmur in a High School Basketball Player
A 15-year-old male basketball player presents for a preparticipation evaluation. Last season he had an episode of syncope during a game while running; he had no prodrome, no chest pain, and no postictal confusion, and he recovered quickly. His maternal uncle died suddenly at age 30. Examination shows a grade 3/6 harsh systolic murmur at the left sternal border that increases with Valsalva and decreases with squatting. His ECG shows LVH voltage criteria and deep T-wave inversions in leads I, aVL, V5, and V6. He is asymptomatic today, has normal vital signs, and wants clearance for the upcoming season.
1. What is your immediate eligibility decision, and why?
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Do not clear him for competitive basketball today. The combination of exertional syncope, a family history of sudden death at a young age, a murmur that increases with Valsalva, and lateral T-wave inversions with LVH voltage is highly concerning for hypertrophic cardiomyopathy (HCM) or another inherited cardiomyopathy.
Exertional syncope is not a benign finding in an athlete. Until evaluation is complete, restrict him from high-intensity exertion, competitive basketball, and conditioning drills. He may perform light activity as tolerated, but he should not train to exhaustion. This is a judgment call in which the cost of missing HCM is far greater than the cost of temporary restriction. Document the restriction and the reason clearly for the family and school.
2. What diagnostic evaluation and counseling should follow?
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Refer urgently to cardiology for:
- comprehensive echocardiography, including provocative maneuvers;
- cardiac MRI if HCM is suspected or echocardiography is inconclusive;
- ambulatory ECG monitoring for arrhythmia;
- genetic counseling and, if HCM is confirmed, family screening;
- review of prior ECGs and any family autopsy information.
Counsel the family that competitive sports eligibility is individualized but that high-intensity and collision sports are generally restricted when HCM is confirmed. Discuss the risk of sudden cardiac arrest, the importance of an AED at games, and the need to avoid stimulants and dehydration. Do not allow him to “play until the echo is back.” If he collapses, emergency action plans should be in place.
3. How would you address the murmur’s behavior with Valsalva and squatting?
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The murmur’s behavior is a key clue. HCM murmurs increase with Valsalva and standing because reduced preload makes the outflow obstruction worse; they decrease with squatting because increased preload and afterload reduce the gradient.
Innocent murmurs usually decrease with Valsalva and may increase with squatting. This patient’s murmur therefore does not fit a benign flow murmur, and it should not be dismissed as an “athletic heart” murmur. The murmur, ECG, syncope, and family history must be interpreted together, not in isolation.
Even if echocardiography is ultimately normal, he needs a clear explanation of why he was restricted and what findings would allow return to play.