How often is dizziness from primary cardiovascular disease true vertigo? A systematic review.

OBJECTIVES: To assess how frequently cardiovascular dizziness is vertigo. Recent studies suggest providers do not consider cardiovascular causes when a patient reports true vertigo (spinning/motion) as opposed to presyncope (impending faint). It is known that cardiovascular disease causes dizziness, but unknown how often such dizziness is vertiginous, as opposed to presyncopal. DATA SOURCES: Systematic review of observational studies was made: Search--electronic (MEDLINE, EMBASE) and manual (references of eligible articles) search for English-language studies (1972-2007). REVIEW METHODS: Inclusions Studies of >or=5 patients with confirmed cardiovascular causes for dizziness and reporting a proportion with vertigo were included. Two independent reviewers selected studies for inclusion, with differences adjudicated by a third. Study characteristics and dizziness-type proportions were abstracted. Studies were rated on methodology and quality of dizziness definitions. Differences were resolved by consensus. RESULTS: We identified 1,506 citations, examined 125 full manuscripts, and included 5 studies. Principal reasons for exclusion were: abstracts--lack of original data, no cardiovascular diagnosis, or confounding exposure/disease (74%); manuscripts--failure to distinguish vertigo from other dizziness types (78%). In the three studies not using vertigo as an entry criterion (representing 1,659 patients with myocardial infarction, orthostatic hypotension, or syncope), vertigo was present in 63% (95% CI 57-69%) of cardiovascular patients with dizziness and the only dizziness type in 37% (95% CI 31-43%). Limitations include modest study quality and non-uniform definitions for vertigo. CONCLUSIONS: Published data suggest that dizziness from primary cardiovascular disease may often be vertigo. Future research should assess prospectively whether dizziness type is a meaningful predictor for or against a cardiovascular diagnosis.

Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians.

OBJECTIVE: To assess emergency physicians' diagnostic approach to the patient with dizziness, using a multicenter quantitative survey. PARTICIPANTS AND METHODS: We anonymously surveyed attending and resident emergency physicians at 17 academic-affiliated emergency departments with an Internet-based survey (September 1, 2006, to November 3, 2006). The survey respondents ranked the relative importance of symptom quality, timing, triggers, and associated symptoms and indicated their agreement with 20 statements about diagnostic assessment of dizziness (Likert scale). We used logistic regression to assess the impact of "symptom quality ranked first" on odds of agreement with diagnostic statements; we then stratified responses by academic rank. RESULTS: Of the 505 individuals surveyed, 415 responded for an overall response rate of 82%. A total of 93% (95% confidence interval [CI], 90%-95%) agreed that determining type of dizziness is very important, and 64% (95% CI, 60%-69%) ranked symptom quality as the most important diagnostic feature. In a multivariate model, those ranking quality first (particularly resident physicians) more often reported high-risk reasoning that might predispose patients to misdiagnosis (eg, in a patient with persistent, continuous dizziness, who could have a cerebellar stroke, resident physicians reported feeling reassured that a normal head computed tomogram indicates that the patient can safely go home) (odds ratio, 6.74; 95% CI, 2.05-22.19). CONCLUSION: Physicians report taking a quality-of-symptoms approach to the diagnosis of dizziness in patients in the emergency department. Those relying heavily on this approach may be predisposed to high-risk downstream diagnostic reasoning. Other clinical features (eg, timing, triggers, associated symptoms) appear relatively undervalued. Educational initiatives merit consideration.