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Avatar universal

Teen swimmer with presyncope and palpitatations

I will try to be succinct.  My 17 year old daughter is a competitive swimmer who is used to training and competing at the highest levels.  She verbally committed to swim at a Division I top 20 program two weeks ago, so in addition to being concerned for her well-being, we are anxious to not interrupt her training any more than necessary.

She has had about 8-10 episodes of presyncope of varying levels of severity in the past three months.  Her symptoms (not all occurring every time) have included:  dizziness, mild nausea, mental confusion, a feeling of disconnectedness from the world, objects seeming smaller than they really are, extreme fatigue, clamminess, and extremely dilated pupils (every time).  

The first time was after an 800 meter race and the very end of a four day meet this summer, which her primary care doc attributed to possible exercise induced hypoglycemia.  She has always been very careful about hydration, eats 6-8 small meals a day with plenty of protein as well as carbs, etc.including at meets, so I was a little doubtful about hypoglycemia but let it slide because she didn't have another episode for two months.  The next one was while sitting in homeroom after having a good breakfast, plenty of water, and a decent night's sleep with no morning practice.  The doc referred her to a cardiologist for possible neurocardiogenic syncope, but it wasn't considered an emergency because "teenage girls often faint," and it wasn't occurring very frequently.

However, starting ten days ago she has had about 8 episodes.  She was taking cold medicines at the time, which I read can cause problems with people with heart issues.  Last week one occurred while in the middle of a practice set but the other two were not while swimming.  When swimming she suddenly feels faint and her muscles feel like they are shutting down.  She has made it to the side and gotten out with assistance each time.  Her coach says her pupils are huge at the time.

We got the cardiologist appt. moved up to last Wed. (10/24) since things seemed to be escalating.  Her EKG (done with only 2-3 contact points - is that considered a full EKG?) was normal.  Her echo was normal except that she has a tiny hole in her heart, which he said up to 25% of the population has.  He gave her a monitor to wear for a week and to push the button if she was having symptoms.  He felt like it was most likely not cardiac in nature but was doing the monitor to be sure, and referred her to a neurologist for possible migraines (even though no headache - but I have read that that you can actually have that) or seizures.  According to him, the hole in heart (BPO?) has been linked to migraines, although hers is tiny.  

Then this week all three more major episodes (some other incidents of momentary symptoms) occurred while swimming.  She tried to get back in the water after resting a little, but was very weak feeling and her heart felt fluttery.  So she has not swam for the past couple of days but has had a couple of fluttery feelings even when not exercising, and after stretching while lying on her stomach, when she sat back up she had a sharp pain in her heart for about five minutes.

Saw the neurologist on Tues, who completely blew her off.  Said it was most likely migraines, but could possibly be seizures, he doesn't seen any clinical reason for the link between the hole and migraines, and that her symptoms were too vague to do anything with and to call if she developed further ones, otherwise come back in Dec.  Jerk.... If we go back on a neuro track we will definitely get a second opinion.

The monitor results are not in yet, but since all the episodes that occurred after she got the monitor were while she was in the water and the monitor was off, it didn't record them when they started.  She did get out and dry off and put it on and push the button, but I don't know if that is helpful. So I called the cardiologist back yesterday, and he scheduled a stress test for tomorrow (Friday).  

I have a few questions if anybody is willing to respond:

1.  The episodes have occurred after swimming a good while, i.e. after warm up and then a little ways in to the main set.  Are they likely to leave her on the treadmill long enough to give an athlete time to get her heart rate up and trigger an episode, or declare everything normal too soon?
2.  If there is some sort of arrhythmia or electrical problem, is it very likely to show up on the stress test?
3.  If the stress test is normal, can we be assured her heart is okay and can she attempt to resume training (although basically she could not train at all this week without feeling bad)? Or are there still more tests to be sure or false negatives to worry about?
4.  Are there any athletes out there who have had similar issues and been able to return to the full level of training and competition?  Maybe through an ablation?  Of course hopefully this isn't even cardiac, but in general I haven't read encouraging things about her potential ability to train while taking beta blockers or with an implantable defibrillator.  

Thanks for any help!
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Avatar universal
Hi - since there have been a few follow-up questions over the years, I thought I'd share the results of my daughter's issues. I'll start at the end and say that she went on to a successful, four-year collegiate swimming career.

Her issues ended being training-related.  I found a physiologist/personal trainer who had been a collegiate swimmer .After much discussion of test results, practices, and monitoring her HR, the trainer determined that she  doing too many anaerobic sets, and the aerobic base she needed for her mid to long distance events had been eroded. Her body was basically staying at a highly stressed, yet exhausted state that it could not sustain.

She took a month off  and then gradually built back up starting with easy aerobic workouts, monitoring her resting HR and also wearing a waterproof HR monitor. By the time she started college she was probably about 85% there, but she was able to do the college workouts and her college coaches were very understanding and let her work back up to 100% at her pace. And she has never had another near-fainting spell.

I am thankful her issues were correctable, and am sorry I can't offer any more guidance to those with syncope and POTS, but I will say that it took a lot of persistence on my part to find this diagnosis and solution, so don't give up!
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2 Comments
Thank you so much for returning worried mom with results! I regret i wasnt on this board in 2012 to participate in a discussion.

Im glad she was able to find a physiologist specialized in swimming because as it turns out the body responds completely differently to this particular exercise. We learn so much from cases such as your daughters.. So as someone interested in these kind of things you truly have my gratitude for coming on here and sharing what you learn. It really helps me as a medical professional, particuarly in the electrophysiology field where so many patients are young athletes, know how to advise folks moving forward.
Also as kind of a general reminder, patient cases are confidential, and theres alot of rules that go into acquiring and using data.

Please if you hear of anyone having a health issue, feel free to encourage them to make their case public. Dont shy away from letting your issue become a training tool or a case study for those of us in the field.

I know sometimes privacy is a concern, or maybe its uncomfortable to have a bunch of people poking and prodding you like a lab rat :p, just remember for every case we study we are often able to take the things we learn and apply it to hundreds of other patients throughout our careers.

This sort of diligent follow-up is still critical.. Even if no sort of pots or some other disease is found, we know have another case to file away to get an idea of the prevelance of disease and what sort of strategies have worked in the past.

In that sense these boards are an invaluable tool. In fact thats why I'm here, everything you guys post is helping me in face to face practice just as much as my posts help you, rest assured.
20748650 tn?1521032211
COMMUNITY LEADER
This is interesting... I wish i had seen this in 2012..

Research has since revealed alot of interesting facts about arrhythmias that are actually comoletely unique to swimming as an exercise...

If anyone else has this issue please do post... Id love to rehash some of the findings and throw some ideas around.
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Avatar universal
My xc/track runner started having episodes over a year ago...his would start in tje height of a race. Worst one happened last Saturday at a race in Charlottesville, he fell twice at end of race and then was.carried to the med tent once he stumbled over thr line.  There has been ckncern because of pvcs on treadmill but monitor has not caught.  Saw neuro yesterday thought maybe exercise induced pots.  He too plans on competing at collegiate level.  I am so uoset and worried.
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Avatar universal
Did you ever get any diagnosis for your daughter? I'm going through the same thing and have for almost 4 years now.. its been a long road.
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967168 tn?1477584489
glad to see you posted in the expert forum and that a doctor answered very quickly =)
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Avatar universal
That she has never actually fainted is a good sign.

I don't want to invoke anxiety as the cause of all this, but dizziness and the other stuff can be related to anxiety, and the physical symptoms of anxiety tend to feed on themselves:  The more you are aware of them--well, the more you are aware of them!

You note that the worst episodes occur after the stress has passed.  During stressful periods, we generate a lot of adrenaline, and the heart rate and blood pressure increase.  When stress is removed, the reverse occurs, and in some people there is a dramatic response to a fall in heart rate and blood pressure:  You can get a somewhat irregular heartbeat and feel quite faint.

Cold medications could be involved, because most of them muck with blood pressure.  Actually, there is a maxim (which athletes do not tend to observe) that if the cold symptoms are below the nose, you shouldn't exercise hard until you're well.



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Avatar universal
Thanks for all the help.  One of her episodes during practice did occur after she had been doing an underwater kick set and then was swimming with a snorkel that limits oxygen intake, so it could have been a type of hyperventilation. Also, I believe somebody she knows has some sort of heart rate monitor they use swimming, so maybe she could borrow it.

It is all a little perplexing because some of the circumstances are confusing.  I worried about the long QT syndrome when I read about it related to exercise, but her EKGs have all been normal.  She has never actually fainted, just felt dizzy and had some of the other symptoms.  She has had some episodes during or after exercising but had some that were nowhere near practice.  She has had a lot of stress and less sleep in the time frame of all this, although the worst episodes have occurred AFTER the stress was over.  She also had two colds during this time and was taking cold meds.
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Avatar universal

Strangely enough, fainting is in fact common in kids, and is generally considered benign by the medical community--except when it occurs in an exercise setting, which is what is going on with your daughter.   When that happens, a tilt-table test is indicated, at the very least.  Here's more on that:

http://www.dukehealth.org/health_library/advice_from_doctors/your_childs_health/fainting

But fainting while swimming is a special case.

This is the most important issue:  Swimming can trigger ‘Long Q-T Syndrome’ in those predisposed to it.  I assume this has absolutely been ruled out by the EKGs your daughter has had (it should have been, for it’s not hard to pick up, and the docs should have been on the alert for it).

Next, immersion and activity in cold water stimulate three odd nervous system responses in pretty much all humans.  First, there’s a thing called a ‘cold shock response’ of the sympathetic nervous system that causes the heart to speed up initially when the body lands in cold water.

Second, when your face is submerged in cold water, the 'dive reflex’ kicks in:  it’s a slowing of the heartbeat.

Third, swimming often involves deep breaths (hyperventilation), which can cause what’s called ‘shallow-water blackout,’ which is potentially dangerous:

http://www.swimmingcoach.org/articles/9903/9903-1.htm

You can see that this is not a simple matter, although it is possible—if ALL other bad things ruled out—that just re-training her breathing patterns might help.

Frankly, I would not allow my daughter to compete until this is well and truly sorted out by a specialist who is familiar with how the heart behaves during swimming.

Perhaps a cardiologist could tell you if one of the heart rate monitors for swimmers would be useful:

http://www.heartratemonitorsusa.com/heart-swim.html
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967168 tn?1477584489
Her near fainting while exercising is what I've gone through my life with Neurocardiogenic syncope and Dysautonomia issues.  Many of the symptoms you list are right in line with what some of us with autonomic dysfunction go through daily - presyncope can be pretty devastating and debilitating.

I've had mixed arrhythmia's and ANS issues since age 9 but didn't find out what it was until age 42 after I had a Tilt table test for fainting and then an ablation and further heart testing which showed I also have Hypertrophic Cardiomyopathy and had a pacemaker/icd implanted.

I can't tell you the number of doctors who told me it was "noting" or everyone faints, its' anxiety, stress or a million other things because they didnt understand. You could mention a TTT to the dr for the unexplained pre-syncope and syncope issues; she really needs to have one to see what's going on.

here's some info on ANS dysfunction/dysautonomia http://www.medhelp.org/health_pages/Neurological-Disorders/Autonomic-Dysfunction-FAQ/show/181?cid=196 if you go back to the link there's more info including doctors who understand and treat patients like us. more info can be found here http://www.cccgroup.info/neurosyn.asp  and the National Dysautonmia Research Foundation has some excellent information http://www.ndrf.org/NDRF%20Patient%20Handbook/SecA_pp59-134.PDF and the main doctor for Dysautonomia Dr. Blair Grubb is there.

please be careful with syncope/pre-syncope; I developed brain damage last year after so many falls because nothing medically or lifestyle changes has helped my symptoms...I'm just  thankful I haven't done more to myself or others fainting or nearly fainting - a fall last year nearly cost me my life luckily it was only a severely sprained neck, contusion and frontal lobe damage.

btw the reason could be as simple as blood pressure and hr that drops too quickly like mine does; not even my pm/icd can catch it in time...it's from mixed signals in the autonomic nervous system and brain

hopefully they find out what's going on and it's something simple and treatable...if it is ANS issues like NCS; meds and lifestyle changes may be beneficial and help alleviate symptoms.



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Avatar universal
Thanks to everyone who has commented thus far - I appreciate the help.  Her stress test this morning was normal, thankfully.  I was not able to be in the room during it due to space issues.  I hope she was on the treadmill long enough.  They inclined it to make it more difficult, but she is a well trained athlete, and her heart rate only got up to 170-180 for a minute at the very end (15 minutes).  I don't know all her readings, but he said there were no arrhythmias, her heart rate and bp were as expected and in line with an athlete, her oxygen levels stayed very high, there were no drop in oxygen levels in the crossover from right to left, meaning the small hole wasn't allowing unoxygenated blood to go to her brain.  She was cleared for all activities.  

She is being referred to a different neurologist to evaluate the migraines/seizure angle since the first neuro blew us off.  But also I wonder if we are back to the neurocardiogenic syncope, or if maybe she does need to see another type of cardiac specialist?  It certainly sounds like it's not cardiac, but I guess we'll see what happens when she tries to resume training.  Everything I read said that near fainting while exercising is a rad flag.

Just learning that exercise might be a trigger for benign near syncope for her is not helpful or a solution since she cannot train like she needs to and will not be able to compete collegiately like she has just committed to as things are now. It'd be one thing if she had a cardiac issue that kept her from competing, but just fainting for no specific physical reason?  Infuriating.
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1807132 tn?1318743597
Considering that your daughter doesn't sense that the heart is acting up during these episodes may mean that whatever is going on is not related to the heart.  A lot of times this happens simply due to the body being out of balance a bit especially if the sodium is low or a person is anemic.  It sounds like you have had her tested and those numbers seem to be fine but a super active person who works out to extremes does need to ensure that her electrolytes do not get depleted when they work out.  If this isn't the case with your daughter then I would suggest trying to find a cardiologist who specializes in dysautonomia.  It is an issue with the autonomic nervous system that is marked by syncope episodes.  If the stress test does not yield any insight then try a dysautonomia doctor and see what they think.  But considering her issues elevated after taking cold medicine I would push to have an echo done if she hasn't had one of those and have them check for long QT.  I would caution against taking cold meds again especially if this becomes a pattern because long QT can sometimes be induced in people after taking cold meds.  Finally I might also question your daughter about how heavy her periods are.  I had a fibroid when I was young that caused heavy bleeding but because I started out with it and my periods were always heavy I did not know any better that they were heavier then they should be.  Subsequently I started to pass out when the anemia started to get more pronounced.  I know your daughter has had her blood tested but it could be a transient issue occurring mainly when her period is around.  So something to look at.  So best of luck with the stress test.  If you can be there with her then make sure you speak up if you feel that things are being rushed too much.  Please do keep us posted on how she is doing.
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4258782 tn?1351826435
The hole in the. Heart that their. Talking about is called a pfo some time the pfo can left blood shunt from the right side of the heart to the lef
t side and when that happens you.  Can have a storke. Or pass out and it can strange the heart out too it fails
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Avatar universal
I think you need to do two things.  One is to post your question in the Heart Disease Expert Forum here, where cardiologists answer the questions:

http://www.medhelp.org/forums/Heart-Disease/show/114

Second, while keeping your daughter on the treadmill until her heart rate maxes out may in fact show something, I suspect you are going to have to take her to an extremely specialized cardiologist, because there are stressors associated with swimming that are somewhat different from what you run into in land-based exercise, and obviously you cannot wear a Holter monitor while swimming.

You ask if three leads is enough on an EKG.  Yes, it is.  A simple one-lead rhythm strip will give you the info you need about the heartbeat.  Using six- or 12-leads will tell you *where* any suspected damage or anatomical problem might be, but in this case, I think you might be looking at a rhythm issue.

Post on the Expert board and see what the doc says.
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Avatar universal
also forgot to say that her bloodwork about a month ago was normal, including blood sugar, thyroid, hemoglobin, etc.
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Avatar universal
I forgot to say also that her heart has not seemed to be racing in any of these episodes.
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