What causes dizziness, palpitations, and near syncope in a 22-year-old male during exercise?

Exercise-Induced Dizziness, Palpitations, and Near Syncope in a Young Adult Male

A 22-year-old male experiencing dizziness, palpitations, and near syncope during exercise should be hospitalized for evaluation, monitoring, and management due to high risk of ventricular arrhythmias and sudden cardiac death. 1

Initial Assessment and Immediate Concerns

High-Risk Features

• Young age (22 years)
• Exercise-triggered symptoms
• Triad of symptoms (dizziness, palpitations, near syncope)
• Occurrence during physical exertion

These features strongly suggest a potential cardiac etiology that requires urgent evaluation, as exercise-related syncope or near-syncope in young adults is a red flag for potentially life-threatening conditions 1.

Differential Diagnosis

Primary Cardiac Causes (Most Concerning)

1. Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)

   • Exercise-induced ventricular arrhythmia
   • Typically presents with exercise-related symptoms in young patients
   • Can lead to sudden cardiac death 1

2. Hypertrophic Cardiomyopathy

   • Most common cause of sudden cardiac death in young athletes
   • Exercise-related symptoms are an ominous sign 1
   • Young age and syncope are risk factors for sudden death

3. Long QT Syndrome

   • Genetic cardiac channelopathy
   • Can cause exercise-induced arrhythmias
   • May present with normal resting ECG 1

4. Brugada Syndrome

   • Genetic cardiac sodium channel disorder
   • Can cause syncope and sudden cardiac death
   • May have characteristic ECG pattern 1

5. Coronary Artery Anomalies

   • Present in approximately 1% of the population
   • Highest risk when anomalous coronary artery courses between aorta and pulmonary artery
   • Can cause exercise-induced ischemia 1

Other Potential Causes

1. Reflex (Neurally Mediated) Syncope

   • Common in young adults but typically not exercise-induced
   • Usually has prodromal symptoms 1

2. Orthostatic Hypotension

   • Unlikely to be exercise-specific
   • More common in older adults or those with autonomic dysfunction 1, 2

Diagnostic Approach

Immediate Testing (During Hospitalization)

1. 12-lead ECG during symptoms if possible

   • Critical to document any arrhythmia during symptoms 1
   • Look for pre-excitation, prolonged QT interval, Brugada pattern, or other abnormalities

2. 12-lead ECG at baseline

   • To identify underlying cardiac abnormalities
   • Look for conduction abnormalities, QT prolongation, delta waves 1

3. Exercise Stress Test

   • Gold standard for exercise-induced symptoms
   • Can provoke arrhythmias and document hemodynamic responses
   • Specifically indicated for suspected CPVT 1

4. Echocardiogram

   • To identify structural heart disease
   • Essential to rule out hypertrophic cardiomyopathy, valvular disease, and anomalous coronary arteries 1

Additional Testing Based on Initial Results

1. Continuous ECG Monitoring

   • To capture intermittent arrhythmias
   • May require extended monitoring if initial tests are negative

2. Cardiac MRI

   • If ARVD/C is suspected based on ECG or echocardiogram findings 1

3. Electrophysiology Study

   • If initial testing suggests an arrhythmic cause but diagnosis remains unclear 1

Management Approach

Immediate Management

• Hospitalization for monitoring and evaluation 1
• Avoidance of exercise until evaluation is complete
• Cardiac consultation

Condition-Specific Management

• CPVT: Beta-blockers, possible ICD placement
• Hypertrophic Cardiomyopathy: Activity restriction, beta-blockers, possible ICD
• Long QT Syndrome: Beta-blockers, avoidance of QT-prolonging medications, possible ICD
• Brugada Syndrome: ICD placement for symptomatic patients, avoidance of triggering medications
• Coronary Anomalies: Surgical correction may be necessary

Key Pitfalls to Avoid

1. Dismissing symptoms as benign in a young person without thorough cardiac evaluation
2. Failing to perform exercise testing when symptoms are exercise-related
3. Attributing symptoms to anxiety or deconditioning before cardiac causes are excluded
4. Allowing return to exercise before complete evaluation
5. Missing genetic cardiac conditions that may have normal resting ECGs

Follow-up

• If initial evaluation is negative but symptoms persist, consider:
  • Extended cardiac monitoring
  • Repeat exercise testing
  • Tilt-table testing if reflex syncope is suspected
  • Genetic testing for cardiac channelopathies

The combination of exercise-induced dizziness, palpitations, and near syncope in a young adult male represents a potentially life-threatening condition until proven otherwise, and requires prompt, thorough cardiac evaluation.