What is the appropriate workup and management for a 24‑year‑old man who experiences progressive tunnel vision, aural fullness, and light‑headedness only while running, with no symptoms at rest, no cardiovascular history, and no chest pain?

Exercise-Induced Presyncope: Workup and Management

This 24-year-old man is experiencing presyncope (not true syncope) during exertion, and the priority is to rule out life-threatening cardiac causes before considering benign autonomic dysregulation.

Initial Risk Stratification

The constellation of tunnel vision, aural fullness, and lightheadedness during running without loss of consciousness meets the definition of presyncope 1. According to ACC/AHA/HRS guidelines, presyncope includes "extreme lightheadedness; visual sensations, such as 'tunnel vision' or 'graying out'; and variable degrees of altered consciousness without complete loss of consciousness" 1. Critically, syncope during exertion is a high-risk feature that raises concern for cardiac-related causes 2.

High-Risk Features Present:

• Exertional symptoms (occurs only while running)
• Young male (cardiac disease can present in this age group)

Reassuring Features:

• No chest pain
• No palpitations mentioned
• No family history of sudden cardiac death noted
• No prior cardiovascular history

Mandatory Cardiac Workup

Despite the absence of chest pain, exertional presyncope mandates cardiac evaluation to exclude structural heart disease, arrhythmias, and coronary anomalies that can cause sudden cardiac death in young athletes.

Essential Initial Tests:

1. 12-lead ECG (immediate)

   • Look for: Long QT syndrome, Brugada pattern, hypertrophic cardiomyopathy (LVH, deep Q waves), arrhythmogenic right ventricular cardiomyopathy, pre-excitation (WPW)
   • This is the cornerstone initial test per syncope guidelines 1

2. Echocardiography

   • Assess for: Hypertrophic cardiomyopathy, aortic stenosis, other structural abnormalities
   • Essential given exertional nature of symptoms 2

3. Exercise stress testing

   • Can reproduce symptoms and unmask exercise-induced arrhythmias
   • Monitor for blood pressure response (failure to augment suggests cardiac limitation)
   • Assess for ischemia (though less likely at age 24 without risk factors)

4. Holter monitor or event recorder

   • Capture rhythm during symptomatic episodes
   • Consider if initial workup unrevealing

Orthostatic Vital Signs

Measure blood pressure and heart rate supine, then at 1,3,5, and 10 minutes of standing 1:

• Orthostatic hypotension: Drop in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg
• Orthostatic tachycardia: Heart rate increase ≥30 bpm (≥40 bpm for ages 12-19)

However, note that orthostatic testing at rest may be normal if symptoms only occur during exertion.

If Cardiac Workup is Normal: Consider Autonomic Dysregulation

Exertional dizziness with tunnel vision in the absence of cardiac pathology strongly suggests autonomic nervous system dysregulation 3. A study of nine patients with purely exertional dizziness found that autonomic challenges were provocative and medications for autonomic dysregulation were effective, with 7 of 9 patients improving substantially 3.

Autonomic Testing (if available):

• Tilt table testing: May provoke symptoms
• Hyperventilation challenge: Can reproduce "spacey" or "foggy" sensations 3
• Note: These patients often don't have spontaneous hyperventilation symptoms but testing can be provocative

Management of Autonomic Dysregulation:

Nonpharmacologic interventions (first-line):

• Increase fluid intake (2-3 liters daily)
• Increase salt intake (6-10 grams daily if no contraindications)
• Compression stockings during exercise
• Gradual exercise conditioning with lower intensity initially
• Avoid rapid postural changes and prolonged standing

Pharmacologic options (if conservative measures fail):

• Fludrocortisone (0.1-0.2 mg daily) for volume expansion
• Midodrine (5-10 mg three times daily) for peripheral vasoconstriction
• Beta-blockers (low-dose) in select cases

Imaging Considerations

Head CT is NOT indicated in this case 2. The ACR Appropriateness Criteria clearly state that head CT has a low yield (5-6.4%) for acute abnormalities in syncope/presyncope, and these are nearly all in patients with external head trauma or focal neurological deficits 2. This patient has neither.

The Aural Fullness Component

The aural fullness is noteworthy but likely represents vascular congestion or pressure changes during exertion rather than primary otologic pathology. True Meniere's disease would present with episodic vertigo, fluctuating hearing loss, and tinnitus—not purely exertional symptoms 4. The aural fullness here is probably a manifestation of the same autonomic/vascular process causing the visual and lightheadedness symptoms.

Critical Pitfalls to Avoid

1. Do not dismiss exertional symptoms in young patients: Sudden cardiac death can occur in structurally abnormal hearts that appear healthy
2. Do not attribute symptoms to "anxiety" or "deconditioning" without cardiac clearance: This is a medicolegal and patient safety imperative
3. Do not order brain MRI as first-line imaging: No focal neurologic deficits or true vertigo present 2
4. Do not confuse presyncope with true syncope: Management is similar, but this patient never lost consciousness 1, 2

Algorithmic Approach

Exertional presyncope in young adult
         ↓
ECG + Orthostatic vitals (immediate)
         ↓
    Abnormal? → Cardiology referral (urgent)
         ↓ Normal
Echocardiogram + Exercise stress test
         ↓
    Abnormal? → Cardiology referral
         ↓ Normal
Consider autonomic testing
         ↓
Trial of conservative measures:
- Hydration (2-3L/day)
- Salt loading (6-10g/day)
- Compression stockings
- Gradual exercise reconditioning
         ↓
No improvement after 4-6 weeks?
         ↓
Consider fludrocortisone or midodrine

The bottom line: Cardiac clearance is mandatory before attributing symptoms to benign autonomic dysfunction, but if cardiac workup is normal, this likely represents exercise-induced autonomic dysregulation that responds well to conservative management and, if needed, pharmacotherapy 3.