The primary systemic conditions causing lightheadedness affecting the heart and cere-brovascular circulation are related to anxiety or other psychiatric disorders. Sometimes, reproduction of a patient's symptoms during hyperventilation is indicative of anxiety-related dizziness; these patients will often admit to generalized anxiety or even panic attack. When accompanied by horizontal nystagmus, however, the presence of cerebellopontine angle tumor must also be considered (19). A positive hyperventilation test, along with a history of cardiac arrhythmias, orthostasis, and carotid bruit, are all common manifestations of altered cerebral flow due to cardiac disease, cerebrovascular compromise, or vasoconstriction. Most commonly, extensive small vessel cerebrovascular disease is found on imaging in elderly patients with additional risk factors such as hypertension, diabetes, and hypercholesterolemia. Occasionally, dysautonomia associated with diabetes or hypoadren-alism can be identified. In many cases, medication effects need to be considered, especially with aggressive antihypertensive therapy and sedative medications in the elderly.
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