How should I manage a patient presenting with vertigo, mild left‑sided chest pain, and abdominal distention?

Management of Vertigo, Mild Left Chest Pain, and Abdominal Distention

This presentation requires immediate systematic evaluation to exclude life-threatening cardiovascular and neurological causes before addressing the vertigo.

Immediate Priority: Rule Out Acute Coronary Syndrome and Aortic Dissection

The combination of chest pain with vertigo and abdominal distention demands urgent cardiovascular assessment, as chest pain presentations require rapid triage to identify life-threatening conditions 1. Obtain an ECG immediately and measure cardiac troponin to exclude acute myocardial infarction or unstable angina 1. The presence of vertigo does not diminish the urgency of evaluating chest pain, as approximately one-third of patients with chest pain transported via ambulance have a final diagnosis of myocardial infarction 1.

Key Historical Features to Obtain

• Chest pain characteristics: Determine if the pain is retrosternal, builds gradually over minutes, radiates to the left arm/neck/jaw, or is associated with dyspnea, nausea, or diaphoresis—all features suggesting angina pectoris 1.
• Cardiovascular risk factors: Age >50 years, hypertension, diabetes, smoking, prior cardiovascular disease, and family history significantly increase the likelihood of acute coronary syndrome 1.
• Pain relief pattern: While nitroglycerin response is not diagnostic (esophageal spasm can respond similarly), document any relief with rest or medication 1.

If the ECG shows ST-segment elevation or cardiac biomarkers are elevated, activate acute coronary syndrome protocols immediately 1. Even mild chest pain can represent unstable angina or non-ST-elevation myocardial infarction, which carry significant short-term risk 1.

Vertigo Evaluation After Cardiovascular Stabilization

Once acute cardiovascular causes are excluded or managed, systematically evaluate the vertigo using timing and triggers rather than the patient's subjective description 2, 3.

Categorize the Vertigo Syndrome

• Brief episodic vertigo (seconds to <1 minute, triggered by head position changes): Suggests benign paroxysmal positional vertigo (BPPV), the most common cause accounting for 42% of vertigo cases 2, 3.
• Acute persistent vertigo (days to weeks of constant symptoms): Suggests vestibular neuritis (41% of peripheral cases) or posterior circulation stroke (25% overall, rising to 75% in high-vascular-risk patients) 2, 4.
• Spontaneous episodic vertigo (minutes to hours without triggers): Suggests vestibular migraine (14% of cases) or Ménière's disease 2, 5.

Critical Red Flags Requiring Urgent MRI Brain Without Contrast

Do not assume a normal neurologic examination excludes stroke—75-80% of posterior circulation strokes present without focal neurologic deficits 2, 6. Obtain urgent MRI with diffusion-weighted imaging if any of the following are present:

• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke), even with normal neurologic exam 2, 6
• New severe headache accompanying vertigo 2, 6
• Severe postural instability with falling 2, 3
• Focal neurological deficits (dysarthria, limb weakness, diplopia, dysphagia, Horner's syndrome) 2, 3
• Pure vertical nystagmus (up-beating or down-beating) without torsional component 2, 3
• Direction-changing nystagmus without head position changes 2, 3
• Baseline nystagmus present without provocative maneuvers 2, 3
• Sudden unilateral hearing loss 2, 6

CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts (sensitivity only 10-20%)—do not substitute CT for MRI when stroke is suspected 2, 6.

Bedside Diagnostic Maneuvers

Perform the Dix-Hallpike maneuver bilaterally to diagnose BPPV 2, 3. A positive test shows:

• Latency of 5-20 seconds before symptoms begin
• Torsional up-beating nystagmus toward the affected ear
• Vertigo and nystagmus that increase then resolve within 60 seconds
• Fatigability with repeated testing 2, 3

If Dix-Hallpike is negative, perform the supine roll test to assess for lateral canal BPPV (10-15% of BPPV cases) 2, 3.

For acute persistent vertigo, the HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for stroke when performed by trained practitioners (superior to early MRI at 46% sensitivity), but is unreliable when performed by non-experts 2, 6. HINTS findings suggesting central cause include:

• Normal head impulse test
• Direction-changing or vertical nystagmus
• Skew deviation present 2, 6

Treatment Based on Diagnosis

If BPPV is Confirmed

Perform the Epley canalith repositioning maneuver immediately—this achieves 80% success after 1-3 treatments and 90-98% with additional maneuvers if initial treatment fails 2, 6. Do not prescribe vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) for BPPV, as they do not correct the mechanical pathology and may delay central compensation 2, 6.

If Vestibular Neuritis is Suspected

Vestibular suppressants may be used briefly for acute symptom relief, but early vestibular rehabilitation is essential to promote central compensation 2, 7.

If Vestibular Migraine is Suspected

Initiate migraine prophylaxis and lifestyle modifications; consider naproxen 500-550 mg plus sumatriptan 50-100 mg orally for acute episodes (avoid in pregnancy/breastfeeding) 2.

If Ménière's Disease is Suspected

Recommend dietary sodium restriction and diuretics; consider intratympanic treatments for refractory cases 2, 6.

Abdominal Distention Assessment

The abdominal distention requires evaluation for potential gastrointestinal causes that may be contributing to the overall presentation. Consider:

• Acute gastric distention or ileus: Can cause referred chest discomfort and may be associated with nausea/vomiting seen in vestibular disorders 1.
• Esophageal disorders: Esophageal spasm can mimic cardiac chest pain and respond to nitroglycerin 1.
• Medication review: Certain cardiovascular medications can cause both dizziness and gastrointestinal symptoms 2.

Perform abdominal examination and consider basic metabolic panel if history or examination suggests specific abnormalities, though routine comprehensive laboratory panels rarely change management 6.

Common Pitfalls to Avoid

• Relying on patient's description of "spinning" versus "lightheadedness"—focus instead on timing, triggers, and associated symptoms 2, 6
• Assuming normal neurologic exam excludes stroke—most posterior circulation strokes lack focal deficits 2, 6
• Using CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 2, 6
• Failing to perform Dix-Hallpike maneuver—approximately 50% of BPPV patients describe symptoms as "lightheadedness" rather than classic vertigo 2
• Ordering routine imaging for typical BPPV—diagnostic yield is <1% without red flags 2, 6
• Overlooking medication side effects—antihypertensives, sedatives, and anticonvulsants are leading reversible causes of chronic dizziness 2, 6

Disposition and Follow-Up

• If acute coronary syndrome is confirmed: Admit for guideline-directed management 1
• If BPPV is treated successfully: Reassess within 1 month to document resolution; counsel about 10-18% recurrence rate at 1 year 6
• If red flags are present: Obtain urgent MRI and neurology consultation 2, 6
• If symptoms persist after appropriate treatment: Consider vestibular rehabilitation therapy, which significantly improves gait stability compared to medication alone 2, 6