What is the appropriate workup for a patient presenting with lightheadedness (dizziness) and shortness of breath (dyspnea)?

From the Guidelines

The appropriate workup for a patient presenting with lightheadedness and shortness of breath should begin with a thorough history and physical examination, followed by targeted diagnostic tests, including chest radiography, electrocardiogram (ECG), and point-of-care ultrasonography (POCUS) as recommended by the most recent evidence 1. The initial evaluation should include vital signs such as blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature. Basic laboratory tests should include a complete blood count to assess for anemia, a basic metabolic panel to evaluate electrolyte abnormalities and kidney function, and cardiac biomarkers such as troponin to rule out myocardial injury.

• An electrocardiogram (ECG) should be performed to detect arrhythmias or ischemic changes.
• Pulse oximetry and arterial blood gas analysis may be necessary to evaluate oxygenation and acid-base status.
• Chest imaging, typically a chest X-ray, should be obtained to assess for pulmonary pathology such as pneumonia, pulmonary edema, or pneumothorax, as suggested by the American College of Radiology 1.
• If cardiac causes are suspected, an echocardiogram can evaluate cardiac structure and function.
• Pulmonary function tests may be appropriate if respiratory disorders are suspected.
• For patients with risk factors for pulmonary embolism, a D-dimer test and possibly CT pulmonary angiography should be considered.
• Additional tests may include a brain natriuretic peptide (BNP) level to assess for heart failure, thyroid function tests, and in some cases, neurological evaluation including orthostatic vital signs if vestibular causes are suspected. The use of POCUS has been shown to improve the correctness of diagnosis in patients with acute dyspnea 1, and its inclusion in the diagnostic workup can help guide immediate patient management.
• The American Thoracic Society has also emphasized the importance of a comprehensive approach to diagnosing and managing dyspnea, given its high prevalence and association with morbidity and mortality 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Initial Assessment

The workup for a patient presenting with lightheadedness and shortness of breath should begin with a thorough medical history and physical examination to identify potential causes.

• The patient's symptoms, such as the duration and severity of shortness of breath, and any associated symptoms like chest pain or palpitations, should be carefully evaluated 2.
• A physical examination should include vital signs, lung and cardiac examination, and assessment for signs of hypoxia or hypotension.

Diagnostic Tests

Based on the initial assessment, various diagnostic tests may be ordered to determine the underlying cause of the patient's symptoms.

• Electrocardiogram (ECG) to evaluate for cardiac causes such as arrhythmias or ischemia 3.
• Chest radiography to assess for pulmonary causes such as pneumonia or pulmonary embolism 3.
• Blood tests, including complete blood count, electrolytes, and D-dimer, to evaluate for conditions such as anemia, infection, or thromboembolism 3, 4.
• Computed tomography pulmonary angiogram (CTPA) to diagnose pulmonary embolism if suspected 3.

Specific Conditions

Certain conditions, such as pulmonary embolism, mitral regurgitation, or cardiogenic shock, may require specific diagnostic tests and management strategies.

• Pulmonary embolism requires urgent treatment with anticoagulation and may involve CTPA for diagnosis 3.
• Mitral regurgitation with severe left ventricular dysfunction may require surgical intervention, such as mitral valve repair, and postoperative hemodynamic support 5.
• Cardiogenic shock may require inotropic support, vasopressors, and mechanical ventilation.

Management

The management of lightheadedness and shortness of breath depends on the underlying cause.

• Oxygen therapy and supplemental oxygen may be necessary to manage hypoxia 6.
• Treatment of underlying conditions, such as heart failure, pneumonia, or pulmonary embolism, is crucial to alleviate symptoms 2, 6.
• Self-management strategies for breathlessness crises, such as relaxation techniques and breathing exercises, may be beneficial for patients with chronic conditions 6.