Vasovagal Syncope in Competitive Rowers
Athletes with a history of vasovagal syncope can generally participate in rowing after appropriate evaluation, provided the syncope is confirmed as benign neurally-mediated (vasovagal) and not associated with high-risk features or exertional triggers. 1
Initial Evaluation Requirements
All competitive athletes with syncope require comprehensive cardiovascular assessment by a provider experienced in treating athletes before resuming competitive sports. 1 This evaluation must include:
- Complete history with witness interviews and video review if available to determine the temporal relationship to exercise—syncope during exercise is high-risk and requires extensive cardiac evaluation, while syncope after exercise is more likely benign vasovagal 1, 2
- Physical examination including orthostatic vital signs (supine and standing blood pressure measurements) 1
- 12-lead ECG to exclude channelopathies, cardiomyopathy, pre-excitation patterns, and conduction abnormalities 1
- Echocardiography to rule out structural heart disease including hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, and congenital anomalies 1
High-Risk Features Requiring Restriction
Syncope warrants immediate restriction from competitive sports participation until evaluation is completed if any of these high-risk features are present: 1
- Unheralded collapse without prodromal symptoms
- Syncope occurring during exercise (not after)
- Abrupt palpitations preceding the event
- Exertional angina or excessive dyspnea
- Family history of sudden cardiac death, collapse, or cardiomyopathy
- Abnormal ECG findings
Return to Play Guidelines for Confirmed Vasovagal Syncope
Once benign vasovagal syncope is confirmed through appropriate evaluation:
Athletes with no syncope in the prior year have no restriction on competitive sports participation. 1
Athletes with 1-6 episodes per year should be symptom-free for 1 month before returning to competitive rowing. 1
Athletes with >6 episodes per year are not fit to participate until symptoms are resolved. 1
Important Caveats for Rowing Specifically
Rowing presents unique considerations as a sport with intrinsic risk—transient loss of consciousness during rowing could result in adverse effects for the athlete and nearby teammates, particularly in sweep rowing or during water training. 1 The European Society of Cardiology specifically notes that sports with intrinsic risk require additional consideration for athletes with neurocardiogenic syncope. 1
Preventive Measures
For athletes cleared to return with confirmed vasovagal syncope:
- Adequate hydration before, during, and after exercise 2
- Counterpressure maneuvers (leg crossing, muscle tensing) when experiencing prodromal symptoms 2
- Avoidance of prolonged standing in hot environments or after intense exercise 1
- Recognition of prodromal symptoms (lightheadedness, nausea, visual changes) to allow sitting/lying down before loss of consciousness 2
Common Pitfalls to Avoid
Do not dismiss syncope in athletes as benign without proper cardiac evaluation—cardiac causes account for 75% of sport-related deaths in young athletes, and syncope may be the harbinger of sudden cardiac death. 1, 3
Do not confuse post-exertional syncope with exertional syncope—the former is typically benign vasovagal related to venous pooling, while the latter is a compelling symptom requiring extensive cardiac workup. 1, 2
Do not rely solely on tilt-table testing in athletes—this test has lower specificity in athletes compared to the general population due to their enhanced vagal tone. 1