Recurrent Syncope in a Child: Red Flags to Consider

A 12-year-old athletic male presents to clinic with six episodes of syncope with exertion while sprinting during track and field competition or playing soccer. The episodes last 1-5 minutes and occur at variable phases of physical exertion. One episode was associated with bowel incontinence and two with urinary incontinence. He describes pre-syncopal symptoms of blurring of vision, fatigue, and non-specific chest pain, but no palpitations. The first episode of syncope occurred at age 5 after hitting his head on a monkey bar. He has had several medical evaluations during which an electroencephalogram, electrocardiogram, 24-hour Holter, and an exercise stress test (performed at age 10), were all reportedly normal. He returns to the cardiology clinic due to recurrent syncope, most recently shortly after competing in a 200m sprint. Physical examination was unremarkable.

Is a normal ECG and an exercise stress test sufficient to rule out cardiogenic causes of sudden death? What are the next steps to work up this patient?

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