European Journal of Cardiovascular Medicine

Dizziness is a symptom that people experience pretty often, and it can be quite debilitating. It can be described in many different ways, like a spinning sensation (vertigo), feeling like you're about to faint (presyncope), unsteadiness, or just a general lightheaded feeling. While it's true that heart problems, such as arrhythmias, heart failure, and low blood pressure when you stand up (orthostatic hypotension), can definitely cause dizziness, it's also true that many other things can cause it, even in people who already have heart disease 1.

It can be a real challenge to figure out why a cardiac patient is feeling dizzy. Doctors might sometimes focus so much on the patient's heart condition that they miss other treatable causes. And that can lead to delays in getting the right treatment, which can affect the patient's quality of life and end up costing more in healthcare 2.

The reasons behind dizziness can vary quite a bit from one population to another, and even from one healthcare setting to another. Studies done in developed countries have shown that inner ear problems, especially a condition called benign paroxysmal positional vertigo (BPPV), are the most common cause of dizziness overall 3. However, we don't have a lot of data on the non-cardiac causes of dizziness specifically in cardiac patients, especially in rural areas of developing countries like India.

Jammu and Kashmir (J&K) is a state in northern India with a large rural population. People living in these rural areas may have limited access to specialized healthcare, and the prevalence of various medical conditions, including heart disease, might be different compared to what we see in cities. This study aims to take a closer look at the non-cardiac causes of dizziness in cardiac patients who go to hospitals in a rural part of J&K. The hope is that this research will give us valuable information about how big of a problem non-cardiac dizziness is in this particular group of people, and that this information can be used to improve how we care for these patients and how we allocate healthcare resources.

Study Design and Setting

This study involved looking back at old medical records—what's called a retrospective chart review. The study was conducted at Govt. Medical College Doda, which serves a mostly rural population in hilly area of, J&K, India.

Study Population

The study included all adult patients (18 years and older) who had already been diagnosed with heart disease and who came to the hospital(s) complaining primarily of dizziness between January 2019 and December 2023. Since our hospital doesn’t have electronic data base, case sheets with diagnosis of dizziness under evaluation were retrospectively analyzed.

 For the purposes of this study, "heart disease" was defined using specific codes from the International Classification of Diseases, Tenth Revision (ICD-10). These codes included, but weren't limited to:

• I20-I25: Ischemic heart diseases (like angina and heart attacks)
• I44-I49: Cardiac arrhythmias (irregular heartbeats)
• I50: Heart failure
• I95: Hypotension (low blood pressure)

Data Collection

We carefully reviewed the medical records of all the patients who met the study criteria. We used a standardized form to make sure we collected the same information from every record. The data we collected included:

• Demographic characteristics: Age, sex
• Cardiac diagnoses: The specific heart conditions the patients had, classified using the ICD-10 codes mentioned above.
• Non-cardiac causes of dizziness: Any diagnoses in the medical records that indicated a cause of dizziness other than a heart condition. These were grouped into the following categories:
• Vestibular disorders (problems with the inner ear, such as BPPV, vestibular neuritis, and Meniere's disease)
• Medication-related (specific medications that were documented as potential causes of the dizziness)
• Neurological disorders (problems with the nervous system, such as peripheral neuropathy, migraine, and cerebrovascular disease)
• Psychogenic factors (psychological factors, such as anxiety disorders and depression)
• Metabolic disorders (problems with the body's metabolism, such as anemia, low blood sugar, and electrolyte imbalances)
• Cervical spine issues (problems with the neck)
• Other non-cardiac causes (any other non-heart-related cause of dizziness)
• Relevant clinical findings: This included things like blood pressure, heart rate, the results of any neurological exams, and the results of any tests done to check the patient's balance.

Data Analysis

We used descriptive statistics to analyze the data. This means we summarized the data in a way that's easy to understand. For things like age, which are continuous variables, we calculated the mean (average) and standard deviation (SD), which tells us how spread out the data is. For things like sex and the non-cardiac causes of dizziness, which are categorical variables, we calculated frequencies (how many times each category occurred) and percentages. We also calculated the proportion of cardiac patients with dizziness who were diagnosed with a non-cardiac cause.

Where it made sense to do so, we compared our findings with data that has been published from other regions and populations. This helped us to put our results into context and see if there were any significant regional differences. We used a statistical software program SPSS to do all of this data analysis.

During the 5-year study period, 2476 patients who had been diagnosed with a heart condition came to the participating hospitals complaining primarily of dizziness. The average age of these patients was 47.5 years, SD of 15, and their ages ranged from 18-91 years. About 1312 (53%) of them were female, and 1164 (47%) were male. Out of 2476 patients in 1437 (58%) patients had a cardiac cause for their dizziness. While as The most common heart conditions among the patients who were experiencing dizziness were:

• Hypertension (I10): 818 (57%)
• Coronary Artery Disease (I20-I25): 331 (23%)
• Heart Failure (I50): 187 (13%)
• Cardiac Arrhythmias (I44-I49): 101 (7%)

In a pretty significant portion of these patients—1039 (42%) the dizziness was found to be caused by something other than their heart condition. Table 1 shows the breakdown of the specific non-cardiac causes that were identified.

Table 1: Non-Cardiac Causes of Dizziness in Cardiac Patients

This study gives us some valuable data about the non-cardiac causes of dizziness in heart patients in a rural area of Jammu and Kashmir. The findings clearly show that a significant 42% of cardiac patients who come in complaining of dizziness are actually experiencing dizziness due to something other than their heart. This really highlights how important it is for doctors to consider all the possibilities when evaluating a dizzy patient, even if that patient is known to have a heart condition 3.

The most common non-cardiac cause of dizziness in the group of patients we studied was vestibular disorders, affecting about 20-30% of them. The most common specific vestibular disorder was BPPV, which accounted for roughly 10-20% of the cases. This is consistent with what studies in other parts of the world have found, with BPPV being reported as one of the leading causes of dizziness overall 4. However, it's worth noting that the specific types of vestibular disorders that affect cardiac patients can vary depending on things like the age of the population, the other health problems they have, and how easy it is for them to access healthcare.

Dizziness caused by medications was also a significant finding, affecting approximately 218 (21%) of the patients. Cardiac patients often have to take multiple medications, including diuretics 135 (13%) and beta-blockers 83 (8%), both of which are known to sometimes cause dizziness as a side effect 5. This really emphasizes how important it is for doctors to carefully review the medications that cardiac patients are taking when those patients complain of dizziness, and to make adjustments if necessary. The rate of medication-induced dizziness in our study is similar to what has been reported in other studies, which have shown that somewhere around 15-10% of dizziness in older adults can be attributed to their medications 6.

Neurological disorders were the cause of dizziness in approximately 10-20 % of the patients. While cardiac patients may be at a higher risk of stroke, we also saw other neurological conditions in this study, such as peripheral neuropathy (approximately 5-10%) and migraine (approximately 3-7%). The prevalence of migraine as a cause of dizziness in our study population is similar to what is typically reported in the general population 7.

Psychological factors were identified as a contributing factor in 135 (13%) of the patients with dizziness. Dizziness as symptom of anxiety disorders 83 (8%) and depression 52 (5%) in our study, and these conditions may be more common in people who have chronic medical conditions like heart disease 8. Our findings are in line with previous research that has found a link between psychological factors and dizziness, particularly in patients who have multiple health problems 9.

Metabolic disorders, such as anemia 73 (7%) and low blood sugar 40 (4%), were less common causes of dizziness in this study population, affecting roughly 11% of the patients. However, it's important to remember that these conditions can contribute to dizziness, especially in people who are already vulnerable 10.

Problems with the cervical spine (the neck) were identified as a cause of dizziness in approximately 116 (11.36% ) of the patients. This condition, often referred to as cervicogenic dizziness, is characterized by dizziness that is associated with neck pain and that is triggered by certain neck movements 16. The exact mechanism behind this type of dizziness is not fully understood, but it is thought to involve altered sensory input from the neck affecting the body's balance system 17.

Comparison to World Literature

In general, the findings of this study are consistent with what has been reported in the broader medical literature about the causes of dizziness. Inner ear problems, medication-related factors, and neurological conditions are all commonly reported causes of dizziness in various populations around the world 11. However, there are some differences worth noting.

The specific prevalence of different non-cardiac causes of dizziness can vary depending on factors such as the average age of the population being studied, the other health conditions they have, and how easily they can access healthcare. For example, peripheral neuropathy might be a more common cause of dizziness in populations with a high rate of diabetes 12, while medication-induced dizziness might be more common in older adults who are taking many different medications 13.

The relatively high proportion of medication-related dizziness that we found in our study highlights the importance of doctors considering the potential side effects of medications when they are evaluating cardiac patients with dizziness. Similarly, the contribution of psychological factors underscores the complex relationship between physical health and mental health in these patients 14. And the identification of cervical spine issues as a cause of dizziness in some of our patients is in line with a growing recognition in the medical community of the connection between the cervical spine and the body's balance system 18.

Limitations

This study does have several limitations that need to be acknowledged. First, because it was a retrospective study, we had to rely on information that was already recorded in medical records. This type of data can sometimes be inaccurate or incomplete. Second, the study was conducted in a single rural area within J&K, which means that the findings may not be generalizable to other populations or other parts of the world. Third, the number of patients in the study was relatively small, which could limit our ability to detect less common causes of dizziness. Fourth, we had to rely on the diagnoses that were documented in the medical records, and these diagnoses may not always reflect the most accurate or comprehensive evaluation of the patient's dizziness. Finally, the study did not include a control group of cardiac patients who did not experience dizziness. Including such a group would have allowed us to make a more direct comparison of the prevalence of non-cardiac causes.

Strengths

Despite these limitations, this study does provide valuable data on the non-cardiac causes of dizziness in a population that has not been studied extensively before. The study specifically focused on cardiac patients, a group in whom dizziness is often assumed to be solely related to their heart condition. The data collected from a rural area of J&K helps us to better understand the healthcare challenges and disease patterns that are present in resource-limited settings. And the fact that we looked at data over a 5-year period gives us a reasonable timeframe for capturing the various causes of dizziness that might occur.

Non-cardiac causes of dizziness are indeed common in cardiac patients in this rural J&K population. Inner ear problems and dizziness caused by medications are particularly frequent. Neck-related issues also appear to be a notable cause of dizziness in this group. These findings really emphasize that it's crucial for doctors to conduct a thorough evaluation of all potential causes when a cardiac patient presents with dizziness, and that this evaluation should include considering non-cardiac etiologies. A comprehensive patient history, a thorough physical examination, and the use of appropriate diagnostic tests are all necessary to pinpoint the underlying cause of the dizziness and to guide the most appropriate treatment. More research, including prospective studies with larger groups of patients and control groups, will be needed to confirm these findings, to identify the specific factors that might put people at a higher risk, and to develop targeted interventions aimed at improving the management of dizziness in cardiac patients in similar settings. Future research should also examine the impact that non-cardiac causes of dizziness, including cervical spine issues, can have on the overall health and quality of life of cardiac patients 15.

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