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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