How to manage a patient with dizziness, history of vertigo, hypotension (low blood pressure), and bradycardia (abnormally low heart rate)?

Management of Dizziness in a Patient with BP 143/71 and Heart Rate 55

This patient does not have hypotension or clinically significant bradycardia, so the dizziness should be evaluated as a primary vestibular or neurologic problem, not a cardiovascular issue. 1

Blood Pressure and Heart Rate Assessment

• BP 143/71 mmHg is not hypotensive – this is actually elevated systolic pressure and does not explain dizziness from a cardiovascular standpoint 1
• Heart rate of 55 bpm is not pathologically bradycardic unless accompanied by symptoms of hypoperfusion, heart block, or hemodynamic compromise 1
• The dizziness is unlikely related to these vital signs and should prompt evaluation for other causes, particularly given the history of vertigo 1

Differential Diagnosis Based on History of Vertigo

Focus on timing and triggers rather than the quality of dizziness to narrow the differential diagnosis 1, 2:

If Episodic and Triggered by Head Movement:

• Benign paroxysmal positional vertigo (BPPV) is most likely – episodes last <1 minute and are provoked by position changes 1
• Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV (looking for torsional upbeating nystagmus) 1
• If Dix-Hallpike is negative but history suggests BPPV, perform supine roll test for lateral canal BPPV 1

If Episodic and Spontaneous (Not Triggered):

• Consider vestibular migraine or Ménière's disease (episodes last minutes to hours) 1
• Ménière's disease typically includes unilateral hearing loss 2

If Continuous/Acute Onset:

• Consider vestibular neuritis, labyrinthitis, or posterior circulation stroke 1
• Perform HINTS examination (head impulse, nystagmus, test of skew) to distinguish peripheral from central causes 2, 3

Critical Exclusions

Rule out postural hypotension even though resting BP is normal 1:

• Measure orthostatic vital signs (BP and HR supine, then after 1 and 3 minutes standing) 2, 4
• Orthostatic hypotension (drop ≥20 mmHg systolic or ≥10 mmHg diastolic) can cause dizziness despite normal resting BP 1, 4

Assess for medication-related causes 1:

• Review all medications, particularly antihypertensives, diuretics, beta-blockers, or vestibular suppressants 1
• If on beta-blockers or other rate-controlling drugs, bradycardia with dizziness may warrant dose reduction 1

Evaluate for central nervous system causes 1:

• Red flags include: new severe headache, focal neurologic deficits, inability to walk, vertical or direction-changing nystagmus 1, 2
• Vertebrobasilar insufficiency can present with dizziness, diplopia, ataxia, or bilateral sensory deficits 1

Diagnostic Approach

Do NOT routinely order imaging or vestibular testing unless there are atypical features or red flags 1:

• No radiographic imaging if diagnostic criteria for BPPV are met without additional concerning signs 1
• No vestibular testing if BPPV diagnosis is clear 1
• Consider MRA or CTA only if symptoms suggest posterior circulation ischemia (vertebrobasilar insufficiency) 1

Treatment Based on Diagnosis

For BPPV (Most Common):

• Perform canalith repositioning procedure (Epley maneuver) immediately 1
• Do NOT prescribe postprocedural restrictions after the maneuver 1
• Do NOT routinely use vestibular suppressants (antihistamines, benzodiazepines) for BPPV 1
• Offer vestibular rehabilitation if symptoms persist 1

For Other Vestibular Causes:

• Vestibular neuritis: vestibular suppressants acutely, then early vestibular rehabilitation 2
• Ménière's disease: salt restriction and diuretics 2
• Vestibular migraine: migraine prophylaxis and trigger avoidance 1

If Medication-Related:

• If on beta-blockers and symptomatic bradycardia with dizziness: reduce beta-blocker dose rather than discontinue 1
• Administer beta-blockers and ACE inhibitors at different times if hypotension is contributing 1
• Consider reducing diuretics if volume depleted 1

Follow-Up

Reassess within 1 month to document resolution or persistence of symptoms 1:

• If symptoms persist, evaluate for unresolved BPPV or underlying peripheral vestibular/CNS disorders 1
• Repeat positional testing if BPPV was initially diagnosed 1

Common Pitfalls to Avoid

• Do not attribute dizziness to "borderline" bradycardia of 55 bpm unless there is heart block or hemodynamic compromise 1
• Do not assume normal resting BP excludes orthostatic hypotension – always check orthostatic vitals 1, 4
• Do not order unnecessary imaging for straightforward BPPV 1
• Do not prescribe vestibular suppressants for BPPV – they delay compensation and are ineffective 1