Evaluating dizziness in the cardiologist’s office

I see a lot of patients who are sent to me for evaluation of dizziness.  On the surface you wouldn’t think a cardiologist would have much to do with a symptom that relates more to the head than the heart, but there is some logic to it—poor blood flow to the brain could lead to dizziness and, since blood flow starts in the heart, that could be the place to look.

While it is true that diminished (or occasional absence of) blood flow from the heart can render a person devoid of the faculties that allow for stable upright posture, true dizziness is rarely the result of impairment of the cardiovascular system.

In order to fully explain the possible sources of dizziness we first need to tease out what is meant by the term itself.  In my experience people can imply vastly different symptoms when they use the term “dizzy,” but in most cases these symptoms fall into three general categories:

1. Lightheadedness. If you want to experience lightheadedness, here are some things you can try.  First, crouch down near the floor and stay there for about a minute. Now, abruptly jump back to the upright position.  In many people this will produce a sensation of “graying out.”  Fighter pilots feel this when they perform aerial maneuvers that result in excessive force tugging down on their bodies (“pulling Gs”).  The vision narrows, light goes gray or even black, but normal sensation resumes within a moment.  During those few seconds you may feel unsteady and could even fall down if it lasts longer.

If this experiment doesn’t produce a sensation of lightheadedness you might have to try a little harder.  A couple hours before going into the crouch try taking a healthy dose of blood pressure pills and a diuretic.  You can magnify this effect even further by allowing yourself to become a somewhat dehydrated—pick the hottest day of the fall season and hit as many Husker tailgate parties you can find.

Now stand up quickly.  As you can see, the addition of antihypertensive drugs and a loss in vascular volume can significantly impair the body’s ability to quickly send blood to the brain right after you transition to the upright position.  The sensation of lightheadedness you have relates to something called orthostatic or postural hypotension.  In people (particularly people with longstanding diabetes) this can be debilitating, but in others it’s mild and quite natural.  I’ve suffered from this for years, as do many tall and thin people do.  Virtually every time I stand up I can count on losing my vision for a second or two.  This is why shorter, stockier people make better fighter pilots—they tend to “gray out” less when there is a shorter distance from the heart to the head.

To have this sensation when you go from a sitting (or crouching) to a standing position is somewhat natural, but to get it spontaneously when you are walking or sitting is very abnormal.  A sudden but temporary lightheadedness in this scenario can indeed be a marker for some type of transient cardiac disorder, such as a rhythm disturbance, and your best bet is to start by testing the heart.  This type of lightheadedness would probably be most correctly classified as pre-syncope, a term that implies the condition of near-fainting.

2. Disequilibrium. Let’s say your walking down your hallway at home and you start to get the perception that you’re tipping to one side.  You stagger to right yourself, but even when you’re ramrod straight and steadied against the wall you can’t escape the feeling that the world is off-kilter.  No, you’re not an extra in the movie Inception; you’re likely suffering from disequilibrium, a disorder that usually involves some part of the neurological apparatus that your body uses to help you tell what’s up and what’s down.  Possible sources of the problem include impairment of the cerebellum of the brain (stroke, tumor), impingement of spinal cord nerves (cervical spondylosis), and generalized neurological disorders such as Parkinson’s disease.

3. Vertigo. This one’s pretty easy to mimic.  Start by finding a local city park that has a well-lubed merry-go-round and a rowdy bunch of kids that want nothing more than to witness an adult reeling and vomiting.  The rest will pretty much happen by itself.  Another way to demonstrate the fun of vertigo is to invite your young nieces and nephews over to your place for an evening of “spin-the-kid-around-in-circles.”  Children love doing this and don’t seem to mind the bumps and bruises they get when they lunge into the book case or coffee table.  Have a supply of Band-Aids at the ready and don’t feed them anything that will stain clothing or rugs.

The inner ear has an intricate mechanism, called the vestibular system, of keeping track of the movement of your head.  I would go into elaborate detail explaining to you the anatomy and function of the semicircular canals, otoliths, and big words like proprioception, but, quite frankly, it’s been 20 years since I last took a physiology course and I can’t really remember how the whole thing comes together.  Suffice it to say, it’s really complicated.

If you mess up the vestibular system you’ll feel as if you are spinning in a circle even when you are standing still.  The most common cause of this impairment is benign positional vertigo (BPV), a disorder that comes as a result of calcium debris building up in the posterior semicircular canal (see what I told you?—big words) and typically manifests itself as a brief, sometimes intense, spinning sensation that accompanies rapid movements of the head.  Laying one’s head down on the pillow of the bed seems to be a common inciting event.

One of my brothers is an ear, nose, and throat specialist and I had a conversation with him recently about BPV.  He claims that there is an easy and effective treatment for this problem that comes in the form of a “maneuver” that is easily done in the office.  What follows is a description of the Epley maneuver from Wikipedia:

The procedure is as follows:

Sit upright.
Turn your head to the symptomatic side at a 45-degree angle, and lie on your back.
Remain up to 5 minutes in this position.
Turn your head 90 degrees to the other side.
Remain up to 5 minutes in this position.
Roll your body onto your side in the direction you are facing; now you are pointing your head nose down.
Remain up to 5 minutes in this position.
Go back to the sitting position and remain up to 30 seconds in this position.

The entire procedure should be repeated two more times, for a total of three times.

During every step of this procedure the patient may experience some dizziness.

Of course, if you’re not the Circue du Soleil type you can always try medication. Call me skeptical, but I have a hard time believing that this sort of thing can provide relief from BPV.  My brother swears by it (as do several of my patients) even if it seems like a throwback to the days of liniments and snake oils.

So, which is it?  Lightheadedness?  If so, start with a look at your prescription medications and think about asking your doctor to look at the heart.  If it’s a balance problem you have, you may want to find a neurologist.  For vertigo—when the room spins even when you don’t—you could end up in the office of an ENT.  In one published study that tallied the various causes of dizziness in a primary care clinic, the breakdown was as follows: BPV 54%; lightheadedness (presyncope) 6%; disequilibrium 2%; and psychiatric 16%.  It was multifactorial in 13% and unknown in 8%.

Whenever I see someone who complains of “dizziness” I try hard to quickly tease out what the patient is really experiencing before I order a single test.  Of course, if patients have difficulty understanding what I mean by the various types of dizziness, I don’t mind taking a few minutes to show them.  After all, it’s not all that hard to find a well-lubed merry-go-round.

Eric Van De Graaff is a cardiologist at Alegent Health who blogs at the Alegent Health Cardiology Blog.

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  • http://www.PhysicalTherapyDiagnosis.com Tim Richardson

    Sorry, Dr. Eric Van De Graaff, but you have posted a description of the Brandt-Daroff re-habituation exercise that is now largely discredited.

    Epley’s Maneuver is performed by a clinician (ENT, GP, or PT), not by the patient, and it takes about five minutes to perform (including set-up).

    First, determine the affected side through history such as side of aural symptoms, direction of fast rotary nystagmus, horizontal Head Impulse Test (h-HIT) or the Dix-Hallpike Maneuver.

    Then, apply the Epley’s maneuver. This is a description of Epley’s for right posterior semi-circular canal dysfunction:

    In long sitting on a plinth with the patient’s arms crossed, turn her head to the right. Advise her that you are going to lay her down quickly. Test validity and treatment response is predicated on the velocity of the movement.

    Lay her supine, quickly, with her head still rotated right 45 degrees and extended over the edge of the plinth 30 degrees. Watch her eyes. You should see brief, intense rotary nystagmus lasting about 10 seconds. The patient will report spinning. Hold for at least 30 seconds total.

    Turn her head only to the left. You will see horizontal nystagmus as you turn her head. This is normal in healthy people. Once turned to the left, she may again experience brief, intense rotary nystagmus. Hold for at least 30 seconds total.

    Now, with her head turned left, advise her to roll onto her left side. She will end up looking at the floor. Since you cannot see her eyes, inquire about symptoms of vertigo. Hold for at least 30 seconds total.

    With her still on her left side, passively turn her head to the right. Watch for nystagmus. Hold for at least 30 seconds total.

    With her head still turned right, help her into the sitting position. She will now be on the opposite side of the plinth. Watch for nystagmus. Also, this position occasionally provokes orthostatic hypotension. Hold for at least 30 seconds total.

    In all test positions, screen for basilar symptoms due to impaired vertebral blood flow: double vision, Horner’s syndrome, ataxia.

    Your numbers were higher than mine: primary care vertigo is about 35% BPPV (ER is about 50%), drug-drug interactions, hypertension and cervical dysfunction accounts for the rest.

    We screen for posterior fossa strokes using HINTS – http://stroke.ahajournals.org/cgi/content/short/STROKEAHA.109.551234v1

    Thank you for the otherwise excellent and well-written post.

    Tim Richardson, PT
    http://www.PhysicalTherapyDiagnosis.com

    • http://www.alegent.com/heartblog Eric Van De Graaff

      Tim,

      Thanks for the clarification. I appreciate your input and expertise.

      Eric

  • http://myheartsisters.org Carolyn Thomas

    Thanks Dr. Eric (and Tim for clarifying) – I absolutely love hearing about non-invasive, no-cost diagnostic tools and treatments. Thanks also for the helpful info on types of dizzyness.

    I’m a heart attack survivor who was initially sent home from the E.R. with a GERD misdiagnosis, despite presenting with textbook heart attack symptoms like crushing chest pain, nausea, sweating and pain radiating down my left arm. Two weeks of increasing debilitating symptoms followed (but hey! at least I knew it wasn’t my heart, because a guy in a white coat with the letters M.D. after his name had told me quite clearly: “It is NOT your heart!” )

    When symptoms became truly unbearable, I finally returned to the E.R. in desperation. This time, a cardiologist was called in. He performed something I later learned is called an abdominojugular test (previously known as hepatojugular reflux) by simply pressing hard with both his hands on my abdomen for about 30 seconds, and then carefully observing the characteristic ‘double flicker’ of a sustained elevated jugular venous pressure – a sign of active or impending heart failure. One might wonder why the guy in the white coat two weeks earlier had not thought to do such a test. Your thoughts on this?

    • http://www.alegent.com/heartblog Eric Van De Graaff

      Carolyn,

      It sounds like a pretty frustrating and frightening experience. I hope you’ve done well since then.

      Why the ER doctor didn’t perform a thorough exam I can’t say. In fairness, a test for hepatojugular reflux, while useful for the diagnosis of congestive heart failure, would be normal in most patients with chest pain brought on by coronary artery disease.

      The moral to your story for us doctors is that we shouldn’t never neglect the most useful test we have at our disposal: our ears. A patient with the classic symptoms of coronary obstruction warrants a thorough cardiac evaluation. I hope that your doctor didn’t neglect further evaluation simply because you are a woman–I’ve long learned to dismiss any tendency to believe that women are less prone to heart attacks than men.

      In your case it sounds like the right thing was done eventually. Good luck in the future!

      Eric Van De Graaff

  • Kathryn Stephens

    Dr., could you talk about Diastolic Heart Failure, where the blood pumping INTO the heart is a problem? Do cardiologists do Impedance Cardiographs?

    Have you ever tested the blood VOLUME of patients who are prone to feeling faint while walking, say, from bedroom to living room, or standing for longer than 5 minutes in one spot?

    Thanks for a very informative and humorously good article.

    • http://www.alegent.com/heartblog Eric Van De Graaff

      Kathryn,

      Please refer to my blog site for a brief discussion on diastolic CHF:

      http://blogalegent.com/Cardiology-Diastology

      You ask about testing blood volume. That’s a challenging issue since the flow to your brain depends more on your body’s blood reservoir than on the absolute volume. The venous system of your body dilates and contracts to accommodate varying levels of fluid volume. If your veins, particularly those in the abdomen and legs, dilate inappropriately while you are upright you can develop lightheadedness or even fainting.

      Autonomic insufficiency is a common problem that results in the body’s inability to regulate its effective blood volume and is exceedingly difficult to treat. Another common culprit is medications, particularly those with anticholinergic or alpha-receptor blocking characteristics.

      Most cardiologists don’t routinely use transthoracic impedence studies. In my opinion this test does not yet have the capability of providing what I feel is the most useful measurement: left ventricular diastolic filling pressure. Interestingly, impedence has been incorporated in to some defibrillators in an attempt to provide a metric that can be followed over time to assess pulmonary edema.

      You’ve asked about a complicated subject and I’m sorry I’m able to give only a cursory explanation. Thanks for the comment.

      Eric Van De Graaff

  • Jon

    Don’t forget about a saddle PE! we just had a guy in the ER with syncope after hopping down off the exam table. Turned out he had a massive PE (d-dimer of >10!). Orthostatic bp’s were neg, but he stayed tachy which led to the PE suspicion :-) . P.s. His spo2 was 100%.

  • Jackie

    It is expensive to order an MRI. But please at least offer your patient a CT-scan before assigning the ‘unknown’ label. My brain tumor would have been found 5 years earlier if a CT had been ordered. My Erythema Nodosum in 1985 was labeled as such. And I was thought to be ‘crazy’ when the ENT declared my sinus was ‘fine’ in 1990…

  • http://www.fancyscrubs.com FancyScrubs

    How about high salt intake? I personally had this problem years ago and it took doctors a while to figure it out but when they did I just eliminated salt and no more dizziness. Is that a common cause?

  • LastoftheZucchiniFlowers

    You might consider asking the patient if they have recently been exposed to any of the aminoglycosides with or without lasix? We are finding many patients who could never tolerate the “Tilt-a-Whirl” as children are quite predisposed to acquiring vestibulopathies with ototoxic drugs in ranges long considered ‘therapeutic’ OR (more commonly if hospitalized) did NOT have the benefit of Peak and Trough levels for one reason or another. Good to know prior to sending off to otology/vestibular testing (a nightmare, as any who have undergone these will tell you)! I’ve personally gone through it, twice – so I speak from personal experience.