Motivation: During patient presentations, saying that a patient is "dizzy" without further qualifiers is sure to trigger further questions. Did dizziness actually mean vertigo or fainting ("presyncope") or unsteadiness? This approach to dissecting dizziness into further subdivisions stems from a 1972 paper which divided dizziness into vertigo, presyncope, disequilibrium, and "vague lightheadedness," with the implication that vertigo stems from vestibular causes, presyncope from cardiovascular causes, disequilibrium from neurological causes, and other dizziness from other causes. This approach, while never rigorously validated, has permeated medicine and has almost become the standard framework for evaluating dizziness. Recently, this approach has been questioned with growing evidence that the various subtypes of dizziness have many overlapping etiologies.
Results: Unlike other posts, I will summarize three articles here that show that the approach of subdividing dizziness may not be valid because many dangerous causes of dizziness have variable presentations.
1. Culic, V., Miric, D. and Eterovic, D. "Correlation between symptomatology and site of acute myocardial infarction." Int. J. Cardiol. (2001) 77: 163-8:
In this paper, the authors attempted to correlate sites of myocardial infarction and symptoms of presentation among 1546 patients. Among the many symptoms, the authors separated feeling of "vertigo" from "faintness." Here are the findings:
SITE OF INFARCTION % WITH VERTIGO % WITH FAINTING
Anterior 11.1 6.2
Inferior 4.7 4.9
Lateral 8.3 4.2
2. Newman-Toker, D.E. and Camargo, C.A. "Cardiogenic Vertigo - true vertigo as the presenting manifestation of primary cardiac disease." Nature Clin. Prac. Neurol. (2006) 2: 167-172.
This is a case report of a 90 year old woman who presented to the ED after saying that "Everything's going around in a circle" followed by a brief period of decreased consciousness without prodromal feelings of palpitations or presyncope. In the ED, presence of vertigo was used to rule out cardiac causes, and patient was admitted to Neurology. Monitoring there revealed periods of transient asystole (14 second pauses) during which the woman had similar feelings of vertigo. Placement of a pacemaker resolved these episodes. This case-report also referred to another study summarized next.
3. Low, PA, Opfer-Gehrking, TL, McPhee, BR, et. al. "Prospective evaluation of clinical characteristics of orthostatic hypotension." Mayo Clin. Proc. (1995) 70: 617-22.
This article examined 90 patients with documented orthostatic-hypotension undergoing tilt-table testing. When patients were put in an upright position, 88% complained of lightheadedness while 37% complained of vertigo with some patients complaining of both symptoms.
Discussion: I thnk that these studies (along with many others) make the point that using the type of dizziness to exclude causes of dizziness is dangerous and can lead to mistakes. Other more validated algorithms have been created (such as using "timing and trigger" by Dr. Newman-Toker), which use the onset of symptoms and factors provoking the symptoms to generate a differential. Also, people experience dizziness in many ways, and the same cause could trigger many symptoms both in the same person and in different people. As far I could tell, there have been no large scale studies which have particularly looked at errors generated by relying on dizziness symptoms. At some level, dizzy is just, well, dizzy.
Results: Unlike other posts, I will summarize three articles here that show that the approach of subdividing dizziness may not be valid because many dangerous causes of dizziness have variable presentations.
1. Culic, V., Miric, D. and Eterovic, D. "Correlation between symptomatology and site of acute myocardial infarction." Int. J. Cardiol. (2001) 77: 163-8:
In this paper, the authors attempted to correlate sites of myocardial infarction and symptoms of presentation among 1546 patients. Among the many symptoms, the authors separated feeling of "vertigo" from "faintness." Here are the findings:
SITE OF INFARCTION % WITH VERTIGO % WITH FAINTING
Anterior 11.1 6.2
Inferior 4.7 4.9
Lateral 8.3 4.2
2. Newman-Toker, D.E. and Camargo, C.A. "Cardiogenic Vertigo - true vertigo as the presenting manifestation of primary cardiac disease." Nature Clin. Prac. Neurol. (2006) 2: 167-172.
This is a case report of a 90 year old woman who presented to the ED after saying that "Everything's going around in a circle" followed by a brief period of decreased consciousness without prodromal feelings of palpitations or presyncope. In the ED, presence of vertigo was used to rule out cardiac causes, and patient was admitted to Neurology. Monitoring there revealed periods of transient asystole (14 second pauses) during which the woman had similar feelings of vertigo. Placement of a pacemaker resolved these episodes. This case-report also referred to another study summarized next.
3. Low, PA, Opfer-Gehrking, TL, McPhee, BR, et. al. "Prospective evaluation of clinical characteristics of orthostatic hypotension." Mayo Clin. Proc. (1995) 70: 617-22.
This article examined 90 patients with documented orthostatic-hypotension undergoing tilt-table testing. When patients were put in an upright position, 88% complained of lightheadedness while 37% complained of vertigo with some patients complaining of both symptoms.
Discussion: I thnk that these studies (along with many others) make the point that using the type of dizziness to exclude causes of dizziness is dangerous and can lead to mistakes. Other more validated algorithms have been created (such as using "timing and trigger" by Dr. Newman-Toker), which use the onset of symptoms and factors provoking the symptoms to generate a differential. Also, people experience dizziness in many ways, and the same cause could trigger many symptoms both in the same person and in different people. As far I could tell, there have been no large scale studies which have particularly looked at errors generated by relying on dizziness symptoms. At some level, dizzy is just, well, dizzy.
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