Syncope and near syncope are great diagnostic challenges in medicine. On the one hand, the symptom may result from a benign condition and pose little or no t hreat to health other than that related to falling. On the other hand, syncope o r near syncope can be the manifestation of a serious underlying condition that poses an imminent threat to life. Patients with a cardiac cause of syncope are a t far greater risk of dying in the first year after an episode of syncope or nea r syncope than individuals with a noncardiac cause. A cardiac cause of syncope should be considered in every patient with syncope or near syn cope, but it is particularly common in older patients or in patients with known structural hear t disease, arrhythmia, or certain electrocardiographic abnormalities. Although m any diagnostic tests may be helpful in the evaluation of syncope and near synco pe, the history, physical examination, and electrocardiogram pinpoint the cause in many circumstances. Syncope after exercise may be due to left ventricular out flow tract obstruction from aortic stenosis or hypertrophic obstructive cardiomy opathy but can also suggest the diagnosis of postexercise hypotension in which a n abnormality in autonomic regulation of vascular tone or heart rate results in vasodilation or bradycardia after moderate intensity aerobic activity. The pati ent discussed in this case highlights the importance of the clinical history in the evaluation of this condition, since the diagnosis was revealed as the patien ts story was described and eventually acted out.
