Dizziness: If Not Vertigo Could It Be Cardiac Disease?

Cardiology Dizziness: if not Maja Susanto vertigo could it be cardiac disease? Background Case study Dizziness is a common presentation in general practice. A woman aged 75 years presented to the emergency However, the symptom of dizziness represents a spectrum of department with recurrent dizziness and fainting pathology from benign to serious. episodes. Objective Dizziness is a common presentation that accounts for about 5% This review provides an evaluation of a patient presenting of primary care visits.1 When a patient describes dizziness, it can with presyncope/syncope. reflect one of four conditions (Table 1).1,2 Unfortunately, patients Discussion tend to use the term dizziness loosely. In the case study described in Dizziness can be a symptom of one of four conditions: vertigo, this article, the patient presented with dizziness followed by fainting presyncope, disequilibrium or light-headedness. It is often episodes, indicating presyncope rather than vertigo. unclear what patients mean by dizziness as they use this term loosely. Hence, clinicians must be vigilant in evaluating She had a history of hypertension, stable familial patients presenting with dizziness and be mindful of red flags haemochromatosis, gastroesophageal reflux disease and that may indicate serious pathology. This review begins with hypothyroidism, which was treated with thyroxine but a case study describing the wide range of causes of dizziness. treatment was ceased due to euthyroid status. She is a Careful history taking and physical examination are pivotal in lifelong non-smoker and drinks three glasses of wine each evaluating patients presenting with dizziness. day with dinner. Her medications include lercanidipine Keywords 20 mg daily, irbesartan 150 mg daily and omeprazole 20 dizziness; diagnosis, differential; heart diseases mg daily. The additional information produces a list of differential diagnoses. Chronic hypertension may cause left ventricular diastolic dysfunction, leading to low cardiac output, which may lead to cardiac arrhythmias.3 Haemachromatosis can contribute to the development of cardiomyopathy.4–6 The accumulation of iron in the myocardium can lead to severe left ventricular diastolic dysfunction that ultimately leads to heart failure and cardiac arrhythmias.5,6 Similarly, over-replacement of thyroxine can lead to a hyperthyroid state, which, in turn, can lead to atrial tachyarrythmias presenting with palpitations and dizziness. On the other hand, hypothyroidism may cause hypotension and bradycardia, which also lead to dizziness. However, in this case, the patient’s euthyroid status rules out these possibilities. A history of gastroesophageal reflux raises the possibility of peptic ulcer development, which may cause anaemia or volume depletion, contributing to her dizziness.3 Lastly, the combination of a calcium channel blocker and an angiotensin receptor blocker may cause postural hypotension. 264 REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 5, MAY 2014 Eight months before her current presentation to the embolism unlikely. Neurological examination was normal, emergency department, while sitting and having lunch, excluding a neurological disorder. The ejection systolic murmur may she had two episodes of sudden dizziness followed account for aortic stenosis and requires further investigation with by syncope lasting for 1–2 minutes. She described a echocardiography. The blood tests are reassuring. prodrome of hot sensation and diaphoresis prior to loss of consciousness. She immediately presented to her GP The patient was admitted for cardiac monitoring. A and her antihypertensive medication was adjusted. An similar episode recurred the next morning, coinciding ECG revealed normal sinus rhythm at 80 beats per minute with 14 seconds of ventricular standstill on telemetry (Figure 1). No further investigation was done at that stage (Figure 2). An echocardiogram showed normal left but she was advised to go to hospital if the dizziness ventricular size, hyperdynamic systolic function, an recurred. ejection fraction of 75% and normal valvular structure. A carotid ultrasound showed no haemodynamically She had been well over the next 8 months but 18 hours significant carotid artery disease. before her current presentation to the emergency On the basis of the telemetry result, the patient’s prodrome of department, she experienced five separate but similar episodes of dizziness while lying in bed. These episodes dizziness and syncopal episode is due to an arrhythmia. The normal were also followed by syncopal episodes lasting between echocardiogram excludes structural heart disease. The ejection a few seconds to 2 minutes. Again, there was no precipitant or sudden change in posture or emotion prior Table 1. Four categories causing a sensation of to the dizziness. This time she was referred to hospital for dizziness1,2 further assessment. Categories Pathophysiology Aetiology The additional information above confirms that the dizziness was Vertigo Vestibular Vestibular pathology neuritis not associated with head movement and was not postural in nature. = spinning sensation Labyrinthitis There was no history of bleeding or volume depletion. It is worrisome Meniere’s disease that the dizziness was always followed by syncopal episodes that Presyncope Reduced cerebral Volume depletion increased in frequency over a period of 24 hours. It is unlikely that = fainting perfusion Neurocardiogenic the dizziness is due to vestibular dysfunction and is more likely to be sensation syncope due to a cardiac arrhythmia such as bradyarrythmia. Dysequilibrium Gait disorder Myelopathy On examination her blood pressure was 155/85 mmHg = imbalance Peripheral when lying down and 175/90mmHg when standing, and sensation neuropathy heart rate was 73 beats per minute. Her temperature Parkinson’s disease was 36.3°C, oxygen saturation was 97% at room air and her random blood sugar was 6.2 mmol/L. Her Glasgow Light- Psychological Anxiety coma scale was 15/15 and she was alert and orientated. headedness disorder Depression = sensation of Cardiovascular examination revealed dual heart sounds disconnection with ejection systolic murmur at the aortic region from the radiating to the carotids. Jugular venous pressure was environment not elevated and there was no pedal oedema or calf tenderness. Lung auscultation was clear and respiratory rate was 20 respirations per minute. Abdominal and neurological examinations were normal. A blood test showed haemoglobin 143 g/L, white cell count 9.7 x 109/L, sodium 137 mmol/L, potassium 4.2 mmol/L, magnesium 0.8 mmol/L, free T4 12.5 pmol/L, thyroid stimulating hormone 0.16 mU/L, iron 24 umol/L, transferrin 26 umol/L, transferrin saturation 46% and ferritin 38 µg/L. Blood pressure was slightly elevated but there was no postural decrease on standing, which suggests safe dosage of the antihypertensive combination and excludes volume depletion. Her heart rate was within normal limits and glucose level was normal, which excludes hypoglycaemia. Her oxygen saturation was Figure 1. ECG of patient X maintained in room air, which makes a diagnosis of pulmonary REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 5, MAY 2014 265 FOCUS Dizziness: if not vertigo could it be cardiac disease? systolic murmur heard in the examination may represent systolic usually associated with compensatory activation of the sympathetic flow murmur. nervous system, which manifests as symptoms of diaphoresis and 2 The patient received a dual-chamber pacemaker with a tachycardia. Presyncope episode is often followed by syncope, lower rate limit of 50 beats per minute. a transient loss of consciousness followed by complete and spontaneous recovery.7 This phenomenon was seen in the case Discussion above. There are multiple causes of presyncope/syncope, which Patients often describe presyncope as a feeling of fainting or can affect people of any age. In general, it can be classified into dizziness. It is caused by global cerebral hypoperfusion and is three broad categories: neurally mediated syncope, orthostatic hypotension and cardiac syncope8 (Table 2). Rarer causes include syncope secondary to neurological, metabolic and psychogenic disorder. Generally, the three categories of presyncope/syncope are associated with three different age groups. Neurally mediated syncope, such as vasovagal or situational syncope, often affect children and young adults.9 A study by Kang et al in children aged 3–18 years showed that syncope may be related to prolonged standing (30%), movement (13%) or a change in body position (9%).9 It may also be situational (ie. provoked by micturition, defecating or coughing).9 Syncope in this age group is usually considered low risk. In middle-aged people (40–70 years), 10–20% of syncopal episodes have a cardiac aetiology.10 Adult athletes often experience exercise-induced syncope, which may be associated with Figure 2. Telemetry of patient X underlying structural heart disease (ie. hypertrophic obstructive Table 2. Etiology of presyncope/syncope8 Neurally mediated syncope Vasovagal syncope Provoked by • pain • fear, emotion • venesection Situational syncope Provoked by • coughing • micturition • defaecation Orthostatic hypotension Primary autonomic failure Lewy body disease Multiple system atrophy Secondary autonomic failure Diabetes HIV neuropathy Postprandial hypotension Drug-induced Anti-hypertensives, diuretics, antidepressants Volume loss Cardiac syncope Arrhythmias Sinus node dysfunction Atrioventricular dysfunction Supraventricular

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