Dr. Sarah Gubara (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Sara Gubara. And today, I'm joined with Dr. Josh Holbert, Medical Director of the Cardiology Exercise Lab and Cardiologist at Children's Mercy. Today, we're exploring syncope in adolescents. Dr. Holbert, thank you so much for taking the time to join us this morning.

Dr. Josh Holbert: Thanks, Dr. Gubara, for having me. I'm really excited to talk about this topic and something that's very prevalent in our community.

Host: Absolutely. Since syncope is so common in kids and teens, what features can help distinguish a benign fainting episode from something that warrants a cardiac workup?

Dr. Josh Holbert: So, syncope or fainting and collapse, as I describe to our patients, is a very common referral that we see in the cardiology clinic. However, it's frequently an encounter our primary care practitioners see and should also feel empowered to manage in their clinical setting.

And so, the most recent joint statement from the American College of Cardiology and the American Heart Association and Heart Rhythm Society states that all pediatric patients who undergo a syncopal episode and should have a syncope evaluation that consists of a detailed history, physical exam, family history, as well as a 12-lead ECG.

Most of these episodes tend to be vasovagal, or also known as a neural-mediated syncope, and those tend to represent around 75% of the pediatric cases that we see overall. However, cardiac syncope can make up anywhere between 2% to 6% of those cases. And so, it carries the risk of sudden cardiac events and death.

And so, features that should raise suspicion and indicate a further cardiac referral include an absence of prodromal symptoms, palpitations within seconds of preceding a loss of consciousness, lack of prolonged upright posture prior to an event, syncope during exercise or triggered by some sort of auditory or surprise emotional stimuli, family history of a sudden cardiac event or an abnormal physical exam or ECG findings should all prompt visiting us in the cardiology clinic.

Host: Wow. So when an athlete presents with syncope, what are some key history questions pediatricians should ask right away?

Dr. Josh Holbert: Obviously, in our pediatric patients communication and discernment can be challenging especially depending on the patient's age. But a key history a-and questions can be pivotal in guiding our clinical judgment and suspicions for further workup. And so, questions such as: did the patient experience a true loss of consciousness or was it just a near fainting episode? Did the event happen during or after the cessation of exercise? Was the collapse abrupt and unrecognized, or was it preceded by a vasovagal prodrome? And what I mean by that is that lightheadedness, dizziness, the feelings of temperature change, feeling hot and flushed and nauseous can all be prodromal symptoms. Were there palpitations and chest pain associated with the syncopal event? What other surrounding situational factors were at play, hydration, dietary habits that day? Was it a very hot day? Were they in a steam shower or a sauna? Were they currently ill at the time with any recent viral illnesses? And then, obviously in our teenagers, it's important to know the social history, such as recreational or performance-enhancing drug use.

And then, lastly, the two other important questions are any prior syncopal episodes that the patient has experienced, and then that family history of cardiac diagnoses, such as any family members with congenital heart disease, arrhythmias. But also, asking not to forget that key question of any patients or family members that have experienced sudden, young or unexplained deaths in other family members

Host: That's wonderful to know what specific things to look for. Now, should pediatricians look for any other specific red flags during exercise or competition that should prompt an urgent cardiac referral to your team?

Dr. Josh Holbert: Yeah. It's something that I really highlight and want to drive home with my patients and families as well. And really, making them knowledgeable why I'm asking specific previous history questions and what I'm really screening for. And so, red flags for syncope include mid-exertional abrupt syncope or collapse with loss of consciousness, is arrhythmia until proven otherwise. So, that's a big one.

Abrupt palpitations preceding an event, particularly if the patient in this day and age has tech that indicated an abnormally abrupt high heart rate, and especially if those high heart rates were not occurring with any strenuous activity. And so, you know, we see a lot of patients that come in with Fitbits or iWatches, things of that nature, that are triggering and alerting them to high heart rates. And so, another piece of key information that we can screen.

Exertional chest pain that is associated with syncope episodes or just exertional chest pain alone at baseline should be sent for an echocardiogram and further assessment. Excessive shortness of breath or dyspnea that limits exercise outside of the normal capacity is something that is a red flag. Multiple syncopal episodes pertinent cardiac family history or family history of sudden cardiac death. All of these things are red flags that should require cessation of activities and sporting events until necessary evaluation and testing is completed.

And also, while I am a cardiologist by trade, you can't forget the non-cardiac exertional symptoms that are associated with collapse and can nonetheless be just as emergent as well. So, things like seizure-like activity with rhythmic jerking movements with the syncopal episode. If this is, at the time, heat illness, possibly experiencing exertional hyponatremia, requires very acute treatment and reversal. And then, sickle cell can also be associated with acute chest pain and collapse. And so, all things outside of the heart that also need to be considered.

Host: So Dr. Holbert, as pediatricians are thinking of sending a patient to cardiology, what initial evaluation can be completed in the primary care setting before that referral is submitted your way?

Dr. Josh Holbert: Initial evaluation, yeah, is absolutely feasible in the primary care setting. And our primary care providers can be a huge aid in the first-line workup. As I stated earlier, obtaining that thorough history and exam, inspecting for those red flags, and then also obtaining that ECG, screening for any abnormalities as well as performing orthostatic vital signs in the clinic, which can identify, you know, a poor hydration status.

And then, also performing targeted labs when the history suggests, you looking for things like anemia, electrolyte derangements, pregnancy, or ingestion. Those are all things that primary care providers should be comfortable obtaining. As we mentioned before, as the director of the cardiology exercise lab, I'll step on my soapbox just for a minute to also reiterate that tilt table testing is of very little and limited utility in pediatric patients. We've seen a lot of rise in referrals of this nature in the TikTok era for concerns of things like dysautonomia and POTS. And so, explaining to families that tilt table test after they do some Google searching does not have robust data in the pediatric realm.

And so, trying to further delineate that and make them understand kind of what the scenario that they are faced with and what they may be receiving in the cardiology clinic. If it sounds, after all this inspection, like a vasovagal syncopal event, primary care providers should feel comfortable in instituting the initial treatments and recommendations to patients to increase their hydration levels supplement salting mechanisms, and encouraging exercise and activity as a conservative prophylactic measurements.

Lastly, if the primary care provider deems that referral is necessary, sending along their key documentation of the up-to-date history, the current up-to-date workup that they have received, and any treatments that maybe they've instituted and the patient has been faithfully attuning to is something that's very, very helpful for us in the cardiology clinic.

And, you know, as I said, I'm from Kansas City and a Chiefs fan. So, we love a good game plan. And so, the primary care providers can be very instrumental in that game plan in helping us treat these patients.

Host: I appreciate you sharing what families might be researching on their spare time because there's a natural part of this process that's anxiety-inducing. And so, I'm curious to know, how do you counsel athletes and families about returning to sports while the evaluation is underway?

Dr. Josh Holbert: it's one of the biggest key components of this type of visit. And it's a very common question when I speak on this topic at other events that providers will come and ask me as well. And it really hinges on the evaluation, right? So if the workup is largely reassuring and benign with episode consistent with a vasovagal syncope, we can clear them right away.

We give them prophylactic interventions to prevent these episodes. And then, we make sure that they have those red flag features that we mentioned earlier that would require further testing past that appointment day. And that may be something like a Holter monitor that we can place on them scheduling and performing an echocardiogram, an exercise stress test. Or if we're concerned about congenital heart disease and coronary abnormalities, we may need to schedule a cardiac CT. And so, it's very important to tell parents if we aren't clearing them right away, that we must restrict patients from their activities until the full and complete evaluation is finished. And obviously, if all this comes back negative, reassuring them that we have done the appropriate workup and that they may rejoin in activities that we clear, but the caveat of watching for those warning signs that we discussed previously.

As a former collegiate football player, I totally get the frustration of being held out, and it's tough to sideline our patients, but it's imperative that we set them up to succeed but also be safe in the arena. Despite our best efforts at times, sudden cardiac events can still happen. And so it's also why every school or athletic activity association should have an emergency action plan or an EAP. And that includes access to an AED CPR-certified staff, and a transportation plan for any incidents that would require further hospital evaluation. And so, I encourage our patients and families to familiarize themselves with these emergency action plans.

And lastly, I'll kind of just plug, like you mentioned, as the sports and exercise cardiologist here at Children's Mercy. We're working to develop in our facility, our own cardiac fitness program and clinics, and that will include patients with and without cardiac pathology. And patients and providers who may desire further guidance or recommendations with sports and activities down the line. And we'll be excited to help them as we continue to develop those clinics in the near future. So, lots of exciting things on the horizon in this great kind of sports time.

Host: That is exciting to know about these future interventions and wonderful work you're doing to get young athletes back to doing what they love.

Dr. Josh Holbert: Yes, exactly. And that's the key thing. And so, it's a large percentage of patients that we see not only in our clinic, but also the primary care provider setting. And so, what we can do to help these athletes get back on the field and feel confident to perform to the best of their abilities is the best medicine for everyone involved.

Host: Well, I appreciate that. That sounds wonderful. Thank you so much, Dr. Holbert, for taking the time to talk to us about syncope in athletes.

Dr. Josh Holbert: Thank you, Dr. Guevara, for having me come speak today. I really appreciate it

Host: Of course. And as a reminder to our audience, claim your CME credits after listening to this fascinating episode today. You can do so by visiting cmkc.link/cmepodcast, and then click the Claim CME button. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm Dr. Sara Gubara, and this has been Pediatrics in Practice, a CME podcast.