Journal of Neurology

https://doi.org/10.1007/s00415-020-10252-4

ORIGINAL COMMUNICATION

Cardiogenic vertigo: characteristics and proposed diagnostic criteria

Hyun Ah Kim1 · Jinhee Ahn2 · Hyoung‑Seob Park3 · Suk‑Min Lee4 · Seo‑Young Choi4 · Eun Hye Oh5 · Jae‑Hwan Choi5 ·
Ji‑Soo Kim6,7 · Kwang‑Dong Choi4,8 

Received: 9 June 2020 / Revised: 26 September 2020 / Accepted: 29 September 2020

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Early identification of cardiogenic vertigo (CV) is necessary to prevent serious complications of cardiovascular diseases.
However, the literature is limited to case reports without detailed clinical features or diagnostic criteria. The aim of this
study was to define characteristics of CV and propose diagnostic criteria. This study included patients with CV diagnosed
at Pusan National University and Keimyung University Hospitals. Demographic, clinical, laboratory, and treatment data
were analyzed. Of 72 patients with clinically suspicious CV, 27 were finally included. The age ranged from 63 to 88 years
(75.1 ± 7.2 years). Recurrent vertigo occurred without syncopal attacks in 52% [95% CI, 32–71], while it preceded (37%
[19–58]) or followed (11% [2–29]) syncope. The patients with recurrent isolated vertigo had suffered from symptoms from
15 days to 5 years until final diagnosis (median 122 days). The vertigo lasted only for a few seconds (93% [76–99]) or a few
minutes (7% [1–24]). Fourteen patients presented with spinning vertigo, and one of them showed spontaneous downbeat
nystagmus during the attack. Accompanying symptoms including chest discomfort, palpitation, headache, arm twitching, and
lightheadedness were found in 70% [50–86]. Between patients with and without syncope, there was no difference in clinical
parameters and results of cardiac function tests. The most common cardiac abnormality during the attacks of vertigo was
bradyarrhythmia (89% [71–98]). Cardiovascular diseases can develop recurrent isolated vertigo without or preceding syncope.
Onset age, duration of vertigo, accompanying symptoms, and underlying cardiac diseases can aid in differentiation from
other vestibular disorders. Early identification of CV would reduce morbidity and mortality associated with cardiac syncope.

Keywords  Cardiogenic vertigo · Syncope · Bradyarrhythmia · Sick sinus syndrome · Vestibular paroxysmia

Introduction

Cardiovascular disease is the second most common cause

of syncope [1]. Since cardiac syncope leads to increased
morbidity and mortality risk, identification and immediate
Hyun Ah Kim and Jinhee Ahn contributed equally to this work.

5
* Kwang‑Dong Choi Department of Neurology, Pusan National University
[email protected] School of Medicine, Research Institute for Convergence
of Biomedical Science and Technology, Pusan National
1
Department of Neurology, Keimyung University School University Yangsan Hospital, Yangsan, South Korea
of Medicine, Daegu, South Korea 6
Department of Neurology, Seoul National University College
2
Division of Cardiology, Department of Internal Medicine, of Medicine, Seoul, Korea
Pusan National University Hospital, Pusan National 7
Dizziness Center, Clinical Neuroscience Center, Department
University School of Medicine and Biomedical Research
of Neurology, Seoul National University Bundang Hospital,
Institute, Pusan, South Korea
Seongnam, Korea
3
Division of Cardiology, Department of Internal Medicine, 8
Department of Neurology, College of Medicine, Pusan
Brain Research Institute, Keimyung University School
National University, National University Hospital, 179,
of Medicine, Daegu, South Korea
Gudeok‑ro, Seo‑gu, Pusan 602‑739, Korea
4
Department of Neurology, Pusan National University
Hospital, Pusan National University School of Medicine
and Biomedical Research Institute, Pusan, South Korea

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 Journal of Neurology

treatment of underlying cardiac disorders are important (CAVB) had permanent pacemaker insertion, while
[2–6]. Cardiac syncope is a diagnostic challenge, however, three with TBS (Patients 12, 15, and 18) received an
when it presents atypically with convulsion or vertigo [7, ablation therapy for atrial fibrillation. One patient with
8]. Indeed, patients with cardiovascular disorders can pre‑ supraventricular tachycardia (Patient 11) had radiofrequency
sent recurrent rotatory vertigo, and brief recurrent vertigo catheter ablation, and the remaining two with ischemic
can be an initial presentation of sick sinus syndrome (SSS) cardiomyopathy (Patients 5 and 27) underwent percutaneous
[9–11]. In this instance, delayed diagnosis may cause seri‑ coronary intervention.
ous medical problems including sudden cardiac death, and
syncope-related trauma. However, systematic studies on Statistical analysis
cardiogenic vertigo (CV) have been sparse without detailed
clinical features or diagnostic criteria. All analyses were performed with SPSS (version 18.0,
This study aimed to define clinical characteristics of CV, Chicago, IL, USA). Continuous variables were compared
and propose diagnostic criteria. with the t test or Mann–Whitney U tests, and nominal
variables were compared with the χ2 or Fisher exact tests.
The significance level was set at p < 0.01.
Subjects and methods
Data availability
Subjects
Anonymized data will be shared by request from any
Patients with CV were retrospectively identified at qualified investigator.
two tertiary academic referral centers (Pusan National
University Hospital and Keimyung University Hospital)
from September 2016 to August 2019. The diagnosis Results
of cardiogenic vertigo was made when the patients had
(1) recurrent vertigo, (2) definite cardiac abnormalities Clinical characteristics of cardiogenic vertigo
documented during the attacks of vertigo, and (3) resolution
of vertigo by proper treatments of the cardiac diseases. Initially, 72 with suspicious CV were included. After
The institutional review boards of Pusan National excluding patients who had other causes (n = 3) or normal
University Hospital and Keimyung University Hospital cardiac function during the attacks of vertigo (n = 37),
approved this study (2002-022-088). All patients provided declined treatment for cardiac diseases (n = 5), and died due
consent for the use of their medical records. to sudden cardiac arrest during the assessment (n = 1), 26
patients were finally subjected to analysis. One additional
Clinical and laboratory evaluation patient (patient 24) was also included for analysis from our
previous report on CV [9]. The patients included 10 men
We collected the data using a structured registration form and 17 women with the age ranged from 63 to 88 years
that included demographic features, clinical characteristics, (75.1 ± 7.2 years) (Table 1).
and the results of vestibular and cardiac function tests. Of 27 patients with CV, recurrent vertigo occurred in
All subjects had full neurological and neuro-otological the absence of syncopal attacks in 14 (52% [32–71]), while
evaluation by the authors (KHA and CKD). Eye movements it preceded (n = 10, 37% [19–58]) or followed (n = 3, 11%
were recorded binocularly at a sampling rate of 60 Hz using [2–29]) syncope (Table 1). The patients with recurrent iso‑
3D video-oculography (SensoMotoric Instruments, Teltow, lated vertigo had suffered from the symptom from 15 days
Germany) or video Frenzel goggles (SLMED, Seoul, to 5 years until final diagnosis (median, 122 days). Four‑
Korea). All participants underwent cardiac function tests teen patients (52% [32–71]) presented with spinning ver‑
including electrocardiogram, chest X-ray, transthoracic tigo during the episodes, while 12 (44% [26–65]) developed
echocardiogram, treadmill test, and 24-h Holter monitors. non-spinning dizziness/vertigo and the remaining one had
Two patients with suspicious ischemic cardiomyopathy directional pulsion without vertigo. The majority of ver‑
(Patients 5 and 27) further received coronary angiography. tigo attacks occurred spontaneously (n = 20, 74% [5–489]),
whereas vertigo was induced by fatigue or physical activities
Treatment strategies in the remaining 7. The frequency of attacks varied from 20
times per day to once a month. The vertigo lasted only for a
Most patients (n = 21, 78% [95% CI, 19–58]) with few seconds in 25 patients (93% [76–99]), and a few minutes
bradyarrhythmia including SSS, tachycardia–bradycardia in the remaining 2. Accompanying symptoms were found in
syndrome (TBS), or complete atrioventricular block 19 patients (70% [50–86]), which included chest discomfort

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 Table 1  Demographic and clinical characteristics of 27 patients with cardiogenic vertigo
Sex/age Cardiac Longest Treatment Syncope Vertigo Ictal Other cardiac
diseases pause strategies onset nystagmus diseases
(s) Onset-to-visit Duration Frequency Spinning Trigger Accompanying
nature factors symptoms
Journal of Neurology

Without syncope (n = 14)

 1 F/69 TBS 9 PPM No 2Y 1–2 s 3/D  +  Exercise, Palpitation ND –
fatigue
 2 F/83 SSS 12 PPM No 3Y A few s 2/D  +  – Lightheaded‑ ND –
ness, arm
twitching,
 3 F/71 TBS 5 PPM No 3Y A few s A few/D  +  – Lightheaded‑ ND –
ness, palpita‑
tion
 4 M/75 CAVB 10 PPM No 3Y A few s 2–7/D – – Lightheaded‑ ND –
ness, nausea
 5 F/78 ICMP 2 PCI No 1 M A few s Dozens/D  +  – Chest ND VT
discomfort
 6 F/69 SSS 7 PPM No 1 M 1 s A few/D  +  – – ND –
 7 M/77 SSS 4 PPM No 15 D A few s 1/D  +  Standing – ND pAF, AP
 8 F/67 SSS 5 PPM No 2 W 2–3 s 1/W – – Chest ND pAF
discomfort
 9 F/80 TBS 5 PPM No 1Y 2–3 m 1–2/D – – Dyspnea, ND AF
chest
discomfort,
headache
 10 F/76 Mobitz type II 2 PPM No 1 W A few s 1/D  +  – Arm ND –
AV block twitching
 11 F/70 SVT 2 RFCA No 1Y A few s 3–4/M  +  – Headache, ND –
palpitation
 12 F/70 TBS 3 AF ablation No 1Y 1 s 3–4/M – Standing – ND AF
 13 F/79 SSS 3 PPM No 1 M A few s 3–4/D – – Both arm ND AF
twitching,
nausea
 14 M/82 SSS 3 PPM No 6 M 10 s 3–4/D – – Headache, ND –
chest
discomfort,
dyspnea
With syncope (n = 13)
 15 M/78 TBS 6 AF ablation After vertigo 2Y A few s 3–4/D – – Chest ND –
discomfort,
both arm
twitching,
headache

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Table 1  (continued)
Sex/age Cardiac Longest Treatment Syncope Vertigo Ictal Other cardiac
diseases pause strategies onset nystagmus diseases

13
(s) Onset-to-visit Duration Frequency Spinning Trigger Accompanying
nature factors symptoms
 16 M/92 TBS 3 PPM After vertigo 5 M A few s 1/M  +  Walking – ND pAF
 17 F/68 SSS 14 PPM After vertigo 15 D 10 s 2–3/D  +  Standing Chest ND –
discomfort,
nausea,
seizure
 18 F/70 TBS 3 AF ablation After vertigo 1Y A few s 1/M – – Chest ND AF
discomfort,
palpitation
 19 F/88 CAVB 23 PPM After vertigo 1 M A few s 10/D – – Nausea ND –
 20 F/77 CAVB 3 PPM After vertigo 2 M 3–5 s 2–3/D – Eating, – ND –
walking
 21 F/88 CAVB 3 PPM After vertigo 1 M A few s 2/M  +  – Nausea ND AF
 22 M/75 SSS 6 PPM After vertigo 3Y 10 s 3–4/D –(directional – – ND AP
pulsion)
 23 M/71 SSS 6 PPM After vertigo 5Y A few s 1–2/M – Swallowing Headache, ND –
cold
sweating
 24 F/67 CAVB 7 PPM After vertigo 3 M 5–10 s 2–3/W  +  – Palpitation, DB AP MS (MVR)
nausea
 25 M/74 CAVB 5 PPM Before 4 M A few s 1/M  +  – – ND –
vertigo
 26 F/73 TBS 6 PPM Before 2Y A few s 6–7/D  +  – – ND –
vertigo
 27 M/63 ICMP 2 PCI Before 2 M A few m 1/M – – Chest ND –
vertigo discomfort,
tinnitus

TBS tachycardia–bradycardia syndrome, SSS sick sinus syndrome, CAVB complete atrioventricular block, ICMP ischemic cardiomyopathy, AV atrioventricular, SVT supraventricular tachycardia,
PPM permanent pacemaker insertion, PCI  percutaneous coronary intervention, RFCA Radiofrequency catheter ablation, AF atrial fibrillation, Y year, M month, D day, W week, s. second, m.
minute, ND not determined, DB downbeat nystagmus, VT ventricular tachycardia, pAF paroxysmal atrial fibrillation, AP angina pectoris, MS mitral valve stenosis, MVR mitral valve replacement
Journal of Neurology
Journal of Neurology

(n = 8, 30% [14–50]), palpitation (n = 5, 19% [6–38]), nau‑ from VP is critical since carbamazepine for the treatment
sea (n = 5, 19% [6–38]), headache (n = 4, 15% [4–34]), arm of VP can result in dysfunction of the sinus node [14].
twitching (n = 4, 15% [4–34]), and lightheadedness (n = 3, Thus, onset age, accompanying symptoms, and underlying
11% [2–29]). We observed spontaneous downbeat nystag‑ cardiac diseases can aid in differentiation. Based on common
mus during the spell of vertigo in one patient (Patient 24) clinical characteristics in our patients, we proposed new
with SSS. Between the patients with and without syncope, diagnostic criteria of CV which included two categories
there was no significant difference in the clinical parameters (definite and probable CV): “Definite CV” fulfils criteria
and results of cardiac function tests (p > 0.05). A–F. (A) recurrent attacks of spontaneous spinning or
non-spinning vertigo; (B) onset over the age of 60; (C)
Cardiac abnormalities associated with vertigo duration of vertigo less than 1 min; (D) documentation of
cardiac diseases during an attack of vertigo; (E) response
The most common cardiac abnormality during the attacks to proper treatments for cardiac diseases; (F) not better
of vertigo was bradyarrhythmia (n = 24, 89% [71–98]) accounted for by another diagnosis. “Probable CV” fulfils
including SSS (n = 9, 33% [17–54]), tachycardia–bradycardia criteria A–D. (A) an attack of spontaneous spinning or non-
syndrome (TBS, n = 7, 26% [11–46]), and complete spinning vertigo; (B) duration of vertigo less than 5 min;
atrioventricular block (CAVB, n = 6, 22% [9–42]) (Table 1). (C) cardiac diseases documented; (D) not better accounted
The longest pause in these patients ranged from 2 to 23 s. for by another diagnosis. Our proposed criteria would be
Other causes for CV were ischemic cardiomyopathy (n = 2, helpful for future establishment of diagnostic criteria of CV
7% [1–24]) and supraventricular tachycardia (n = 1, 4% verified in a large number of population of cardiovascular
[0–19]). Some patients had other cardiac diseases including cases with comparison to dizziness patients without CV
atrial fibrillation (n = 8, 30% [14–50]), angina pectoris diagnosis (Table 2).
(n = 3, 11% [2–29]), and valvular heart diseases (n = 2, 7% Approximately half of our patients presented with rotatory
[1–24]). vertigo due to cardiovascular diseases, and we observed
objective vestibular dysfunction (downbeat nystagmus)
during the episode in a patient with SSS. Our results provide
Discussion evidence supporting earlier findings that rotatory vertigo
may be frequent among patients who experience dizziness
Our study showed that patients with cardiovascular diseases due to cardiovascular diseases including acute myocardial
can develop recurrent isolated vertigo in the absence of infarction, orthostatic hypotension, and neurocardiogenic
syncopal attacks, and had significant time delay from the syncope [11, 15, 16]. Rotatory vertigo and pure downbeat
symptom onset to diagnosis. Unfortunately, one patient with nystagmus without any other neurologic symptoms reflect
suspicious CV suddenly died due to cardiac arrest during that CV is more likely to result from cerebellar rather than
the assessment. These results emphasize that early diagnosis labyrinthine or brainstem ischemia.
of CV is crucial to reduce morbidity and mortality due to Cardiac syncope accounts for 15% of all syncopal events,
cardiovascular complications such as embolic stroke, cardiac and underlying cardiac problems may be a rhythm distur‑
arrest, and syncope-related trauma [2–6]. Indeed, 1-year bance, a structural problem, or a structural problem that
mortality of cardiac syncope estimates to about 30% [1, 9].
Our 27 patients with CV showed common clinical
Table 2  Proposed diagnostic criteria for cardiogenic vertigo
characteristics. The CV occurred in patients over the age
of 60 (mean age of 75 years). The attacks mostly occurred Definite cardiogenic vertigo (each point needs to be fulfilled)
spontaneously, and it could be also provoked by fatigue or  A) Recurrent attacks of spontaneous spinning or non-spinning
physical activities. The CV is frequently accompanied by vertigo
other cardiac or neurological symptoms including chest  B) Onset over the age of 60
discomfort, palpitation, nausea, headache, arm twitching,  C) Duration of vertigo less than 1 min
lightheadedness, and dyspnea. Remarkably, the duration of  D) Documentation of cardiac diseases during an attack of vertigo
CV was only a few seconds (93%) or minutes (7%) which  E) Response to proper treatments for cardiac diseases
meets the diagnostic criteria of vestibular paroxysmia (VP)  F) Not better accounted for by another diagnosis
[12, 13]. The VP is a rare vestibular disorder characterized Probable cardiogenic vertigo (each point needs to be fulfilled)
by brief attacks of spinning or non-spinning vertigo which  A) More than one attack of spontaneous spinning or non-spinning
vertigo
also lasts from a second up to a few minutes. Arteries
 B) Duration of vertigo less than 5 min
or rarely veins in the cerebellar pontine angle are the
 C) Cardiac diseases documented
pathophysiological cause of a segmental, pressure-induced
 D) Not better accounted for by another diagnosis
dysfunction of the eighth nerve. The discrimination of CV

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 Journal of Neurology

predisposes a patient to a rhythm disturbance [4]. In the References

present study, the most common cause of CV was bradyar‑
rhythmia including SSS, TBS, CAVB, and Mobitz type II 1. Waytz J, Cifu AS, Stern SDC (2018) Evaluation and management
AV block, and only a few patients had tachyarrhythmia and of patients with syncope. JAMA 319:2227–2228
2. Albassam OT, Redelmeier RJ, Shadowitz S, Husain AM, Simel
ischemic cardiomyopathy. When the heart fails to gener‑ D, Etchells EE (2019) Did this patient have cardiac syncope?:
ate adequate cardiac output, the brain is inadequately per‑ The rational clinical examination systematic review. JAMA
fused and temporarily malfunctions, leading to a syncopal 321:2448–2457
event. In bradyarrhythmias, the heart is too slow to generate 3. Ungar A, Rafanelli M (2018) Syncope: electrocardiographic and
clinical correlation. Card Electrophysiol Clin 10:371–386
enough flow, resulting in cerebral hypoperfusion, while tach‑ 4. Martow E, Sandhu R (2019) When is syncope arrhythmic? Med
yarrhythmias force the heart to pump so fast that it leads to Clin N Am 103:793–807
an ineffective ventricular filling and reduced cardiac output. 5. Koene RJ, Adkisson WO, Benditt DG (2017) Syncope and the risk
Likewise, mechanical obstructions to blood flow and car‑ of sudden cardiac death: evaluation, management, and prevention.
J Arrhythm 33:533–544
diac output in structural cardiac diseases will have similar 6. Klein GJ, Gulamhusein SS (1982) Undiagnosed syncope: search
effects but through diverse mechanisms. We can assume that for an arrhythmic etiology. Stroke 13:746–749
transient or small reduction of brain perfusion caused by car‑ 7. Lempert T, Bauer M, Schmidt D (1994) Syncope: a videometric
diovascular diseases would develop isolated vertigo without analysis of 56 episodes of transient cerebral hypoxia. Ann Neurol
36:233–237
loss of consciousness. However, the longest pauses between 8. Jolobe O (2010) Potential causes of delayed diagnosis include
our patients with and without syncope were not significantly convulsive syncope and cardiogenic vertigo. QJM 103:59
different. Whether CV develops in isolation or accompa‑ 9. Choi JH, Yang TI, Cha SY, Lee TH, Choi KD, Kim JS (2010)
nies syncope might be determined by diverse factors such Ictal downbeat nystagmus in cardiogenic vertigo. Neurology
75:2129–2130
as duration or amount of brain hypoperfusion, individual 10. Newman-Toker DE, Camargo CA Jr (2006) ‘Cardiogenic vertigo’–
variations of the cerebral vasculature, and difference in the true vertigo as the presenting manifestation of primary cardiac
individual susceptibility to decreased perfusion. disease. Nat Clin Pract Neurol 2:167–172 (quiz 173)
The limitations of the current study are the retrospective 11. Newman-Toker DE, Dy FJ, Stanton VA, Zee DS, Calkins H, Rob‑
inson KA (2008) How often is dizziness from primary cardiovas‑
nature, selection bias, small number of patients, and lack of cular disease true vertigo? A systematic review. J Gen Intern Med
verified diagnostic criteria at thfe beginning of the study. 23:2087–2094
Furthermore, since we used 24-h Holter monitors, we may 12. Strupp M, Lopez-Escamez JA, Kim JS, Straumann D, Jen JC,
have failed to document arrhythmia during the attacks of Carey J, Bisdorff A, Brandt T (2016) Vestibular paroxysmia: diag‑
nostic criteria. J Vestib Res 26:409–415
vertigo in approximately half of our patients with suspicious 13. Brandt T, Strupp M, Dieterich M (2016) Vestibular paroxysmia:
CV. a treatable neurovascular cross-compression syndrome. J Neurol
263(Suppl 1):S90–S96
Compliance with ethical standards  14. Johnson CD, Rivera H, Jimenez JE (1997) Carbamazepine-
induced sinus node dysfunction. P R Health Sci J 16:45–49
15. Choi JH, Seo JD, Kim MJ, Choi BY, Choi YR, Cho BM, Kim JS,
Conflicts of interest  We have no disclosure of any competing interest. Choi KD (2015) Vertigo and nystagmus in orthostatic hypoten‑
sion. Eur J Neurol 22:648–655
Ethical approval for research involving human participants and/or ani- 16. Kim HA, Bisdorff A, Bronstein AM, Lempert T, Rossi-Izquierdo
mals  All experiments followed the tenets of the Declaration of Hel‑ M, Staab JP, Strupp M, Kim JS (2019) Hemodynamic orthostatic
sinki, and this study was approved by the Institutional Review Board dizziness/vertigo: diagnostic criteria. J Vestib Res 29:45–56
of Pusan National University Hospital (2002-022-088).

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