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• the practical approach also requires recognition of cardiogenic vertigo
  oscar,m jolobe
  Published on: 26 July 2010

• Published on: 26 July 2010

  the practical approach also requires recognition of cardiogenic vertigo

  • oscar,m jolobe, retired geriatrician

  Over and above the recommendation that clinicians should have a low threshold for lying and standing blood pressure measurements in the elderly, even when the history is not typical(1), mention must also be made of the role of cardiac investigations such as telemetry, so as to identify conduction defects as an underlying cause in patients who present with vertigo(2), even though this issue was not raised by the authors. Th...

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  Over and above the recommendation that clinicians should have a low threshold for lying and standing blood pressure measurements in the elderly, even when the history is not typical(1), mention must also be made of the role of cardiac investigations such as telemetry, so as to identify conduction defects as an underlying cause in patients who present with vertigo(2), even though this issue was not raised by the authors. The occurence of so-called "cardiogenic vertigo" as a presenting symptom of sinus node disease was exemplified by a 90 year old woman who had a history of "spells" with mixed vertiginous and non-vertiginous dizziness spanning more than a decade. Seven years after the onset of these spells she began to have syncopal attacks as well, and the eventual underlying diagnosis was elucidated by cardiac telemetry which documented transient asystole during a syncopal episode. When asked afterwards what symptoms she had experienced in association with that particular syncopal episode, she said she had experienced a spinning sensation shortly before her faint. On follow up one year after implantation of a single chamber ventricular pacemaker, she had had no more recurrent symptoms(3). Vertigo may be a symptom even in patients with confirmed orthostatic hypotension on tilt table testing. This was the case in 37% of 90 patients who experienced symptoms in association with either a decrease of 30 mm Hg or more in systolic blood pressure(BP)or a decrease of 15 mm Hg or more in diastolic BP, or a decrease of 20 mm Hg or more in mean BP after a 5 minute duration tilt of 80 degrees or more(3). A more acute presentation of cardiogenic vertigo is the one associated with myocardial infarction, exemplified by the fact that, in one study, 8% of 1546 patients with myocardial infarction described vertigo as one of their presenting symptoms(4). Accordingly, although "common vestibular diagnoses can be found if specifically looked for in the elderly who complain of vague disequilibrium"(1), vestibular symptomatology does not necessarily rule out significant underlying cardiac pathology.

  Reference:

  (1)Bronstein AM., Lempert T., Seemungal BM Chronic dizziness: a practical approach Practical Neurology 2010;10:129-139

  (2)Newman-Toker DE., Camargo CA "Cardiogenic vertigo"-true vertigo as the presenting manifestation of primary cardiac disease Nature Clinical Practice Neurology 2006;2:167-172

  (3)Low PA., Opfer-Gehrking TL., McPhee BR et al Prospective evaluation of clinical characteristics of orthostatic hypotension Mayo Clinic Proceedings 1995;70:617-622

  (4)Culic V., Miric D., Eterovic D Correlation between symptomatology and site of acute myocardial infarction International Journal of Cardiology 2001;77:163-168

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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