Exercise evaluation and sports participation in heart disease — branching viva

Branch 1 — The immediate decision (3 minutes)

Examiner: The coach wants this signed today. What do you do, and why? ^[2]

Candidate: I do not sign the clearance. Syncope that occurs DURING exertion, with no prodrome, combined with a family history of sudden unexplained death before 50, is a red-flag combination that halts clearance. Her rapid recovery does not make this benign — vasovagal syncope has a prodrome of warmth, nausea, and visual disturbance and occurs on standing or after effort, never mid-race. I would arrange a 12-lead ECG (already done, borderline), echocardiography, Holter monitoring, and an exercise stress test to look for exercise-provoked arrhythmia, because the resting ECG and echocardiogram may be normal in the child who collapses on the field. I would refer urgently to paediatric cardiology before any return to sport. ^{[12] [13]}