Dipartimento per le Malattie Cardiovascolari, Ospedale S. Filippo Neri, via G. Martinotti 20, Rome 00135, Italy
* Corresponding author. Tel.: +39-06-50912387; fax: +39-06-33062489
E-mail address: furcol{at}rdn.it
The Italian legislation mandates preventive cardiovascular screening for all subjects engaged in competitive athletic activities.1 Such evaluation is performed by physicians with an academic training in sports medicine, and includes history, physical examination, standard 12-lead electrocardiography and a limited exercise testing (Montoye step test).1 In case of any relevant abnormality, the athlete can be either immediately and permanently disqualified or referred for further cardiovascular evaluation to a clinical center with a specific expertise. All of the athletes included in our recently published study followed such established process and were addressed to our syncope clinic, a tertiary referral institution, for recurrent unexplained exercise-related syncope.2 In particular, all syncopal episodes were considered unexplained by the physicians initially evaluating the athletes, who neither diagnosed a specific disease requiring immediate disqualification, nor found a clear explanation for the exercise-related spells and eventually resolved for referral. At our syncope clinic, an extensive cardiac evaluation was carried out in all of these athletes. In fact, all subjects underwent a complete non-invasive assessment followed by invasive electrophysiological study. We feel that such an approach is reasonably effective in disclosing any significant cardiac abnormality, besides being currently recommended by singleexperts3 and scientific societies.4 Overall, all the available data suggest that the syncopal spells reported by our athletes could be related to a neurocardiogenic reflex.
As to the specific problem of the inherited abnormalities of the cardiac ion channels, we certainly agree that both the long QT syndrome and the Brugada syndrome may be present in structurally normal hearts.5 However, we think that the absence of any significant abnormality in the 12-lead electrocardiogram, Holter recording, exercise electrocardiography and invasive electrophysiological study makes the presence of the above-mentioned electrical diseases highly unlikely even in patients with syncope.
Finally, our athletes have all continued their competitive activity and, until today, they have been followed for a mean period of more than 50 months. Besides, during the follow-up period the athletes have all undergone the yearly preventive assessment required by the Italian legislation.1 Symptomatic subjects with any significant cardiac disease could have been expected to show some form of disease progression or adverse clinical event during such a period time, particularly when involved in intense competitive efforts. In our opinion, such findings further support the idea that theunderlying pathophysiology of the syncopal episodes should have been benign in nature.
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