Passing Out at the Finish Line: When
Fainting Signals a Heart Problem
By KEVIN HELLIKER
November 8, 2005; Page D1

During an eighth-grade cross-country meet, 13-year-old Nicholas
Ballesteros sprinted across the finish line, walked a few feet and
passed out -- thereby running headlong into medical controversy.

When an athlete passes out during the middle of a race, medical
protocol clearly calls for a cardiac evaluation to be performed.
Passing out is a known symptom of cardiac defects, and cardiac defects
are the primary cause of sudden death in athletes.

But when an athlete passes out past the finish line, medical experts
are divided on whether a cardiac evaluation is needed. This isn't
because cardiac disease is less likely to display symptoms just past
the finish line; in fact, the dramatic shift from sprint to sudden
cessation can trigger an episode of cardiac-defect-induced fainting.
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The problem is, that same shift can induce fainting from other causes,
particularly a benign one called exercise-associated collapse. This
happens when the sudden cessation of exercise sends blood pressure
plummeting, slowing the flow of blood to the brain and causing
syncope, the medical term for fainting.

For exercise-associated collapse, the suggested treatment is simple:
Raise the athlete's feet above the head to speed blood flow to the
brain. If that technique triggers a rebound, "then I don't think
further evaluation is warranted in most circumstances," says Andrew
Gregory, a Vanderbilt University pediatrician and sports-medicine
specialist. Indeed, a March 2003 article in the journal Physician and
Sportsmedicine examines the causes of post-finish-line fainting --
without discussing cardiac defects as a possibility.

This surprises Stuart Berger, director of the heart center at
Children's Hospital of Wisconsin. "In my specialty there is no
controversy about this," says Dr. Berger, a pediatric cardiologist.
When athletes faint during or immediately after exercise, "they need a
thorough cardiac workup," he says. That means the administration of an
electrocardiogram to monitor the rhythm of the heart, and an
echocardiogram to study the structure of the heart. Eric Small,
chairman of the sports-medicine council of the American Academy of
Pediatrics, agrees: "If syncope occurs past the finish line, you can't
assume that it's benign," he says. "It has to be investigated."

Drs. Berger and Small agree that fainting beyond the finish line most
often will turn out to be the result of low blood pressure. But the
worst-case scenario must be considered -- and too often isn't, they
say. The danger applies both to adults and children, but the symptoms
in children are more often overlooked because of the misguided
perception that heart disease is a plague of the middle-aged and older.
[Health Journal]
Nicholas Ballesteros plays soccer today, after having a heart defect
repaired.



The number of deaths associated specifically with fainting after
exercise hasn't been tracked. The medical literature often states that
sudden cardiac death in young athletes claims fewer than 25 American
lives a year. But these have been rough estimates, and the actual
number is between 200 and 300, says Barry Maron, a Minneapolis Heart
Institute Foundation cardiologist who is compiling a registry of such
deaths to better track them. An International Olympic Committee report
issued last year estimates that competitive young athletes suffer
sudden cardiac death at three times the rate of their nonathletic peers.

After such a tragedy occurs, it isn't uncommon for a parent to recall
an earlier fainting episode that failed to raise any alarms. "When you
investigate these deaths, you often find that there were symptoms,"
says Paul Thompson, director of the athletes' heart program at
Hartford Hospital in Connecticut.

The fainting episode of Nicholas Ballesteros didn't alarm either his
parents or coach. Recovering quickly, the boy attributed the collapse
to dehydration. "We didn't think much about it," says Mithra
Ballesteros, the boy's mother.

To her immediate regret, however, she mentioned the episode to her
father, Manoochehr Sharifi, a retired Chicago-area pediatrician. Dr.
Sharifi had previously encountered a case of exercise-related syncope
that turned out to be symptomatic of a potentially fatal cardiac
condition called Long QT Syndrome.

At her father's insistence, Mrs. Ballesteros took Nick to his
pediatrician, who performed an electrocardiogram, or EKG. The test
showed a normal heart rhythm. This satisfied the pediatrician, says
Mrs. Ballesteros, and it satisfied her, too. Not, however, her father.
Among other things, Dr. Sharifi says, "I thought Nicholas should have
an echocardiogram." An EKG is around $100, but an echo can run as high
as $1,000; insurance will usually pay.

Reluctantly, Mrs. Ballesteros got a referral to a cardiologist to
perform the echocardiogram -- Dr. Berger in Milwaukee. The day of the
appointment, Mrs. Ballesteros says she nearly canceled it. She felt
certain the appointment would be a waste of time. And "I had a ton of
things to do," says the mother of four. But knowing her father would
expect a report, she kept the appointment.

The news turned out to be bad: Nicholas had an anomalous coronary
artery. The vessel, carrying freshly oxygenated blood, took the wrong
route from the aorta to the heart, exposing it to the possibility of
compression, which would deprive the heart of blood, and which would
be especially likely to happen during exercise. Anomalous coronary
arteries are the second-leading cause of sudden death in young
athletes, after another defect, hypertrophic cardiomyopathy.

Nicholas underwent surgery to repair the artery and is now healthy.
Two years later, he plays high-school soccer. It will never be known
for sure whether the defect caused the fainting spell. But the
fainting unquestionably led to the uncovering of the defect. "My
father saved my son's life," she says.