SUMMARY
Benign paroxysmal positional vertigo (BPPV) is the most common type of peripheral vertigo. BPPV often relapses after the first episode, with a recurrence rate between 15% and 50%. To date both the aetiopathogenetic processes that lead to otoconia detachment and the factors that make BPPV a relapsing disease are still unclear, but recent epidemiological studies have shown a possible association with cardiovascular risk factors. The aim of the present study (Sesto Senso Survey) was to evaluate in the Italian population through an observational survey, the main demographic and clinical characteristics of patients with BPPV (first episode or recurrent) with particular focus on the potential cardiovascular risk factors. The survey was conducted in 158 vestibology centres across Italy on 2,682 patients (mean age 59.3 ± 15.0 years; 39.1% males and 60.9% females) suffering from BPPV, from January 2013 to December 2014. The results showed a high prevalence of cardiovascular risk factors such as high blood pressure (55.8%), hypercholesterolaemia (38.6%) and diabetes (17.7%), as well as a family history of cardiovascular disease (49.4%). A high percentage of patients also had hearing loss (42.9%), tinnitus (41.2%), or both (26.8%). The presence of hypertension, dyslipidaemia and pre-existing cardiovascular comorbidities were significantly related to recurrent BPPV episodes (OR range between 1.84 and 2.31). In addition, the association with diabetes and thyroid/autoimmune disease (OR range between 1.73 and 1.89) was relevant. The survey results confirm the significant association between cardiovascular comorbidities and recurrent BPPV and identify them as a potential important risk factor for recurrence of BPPV in the Italian population, paving the way for the evaluation of new therapeutic strategies in the treatment of this disease.
KEY WORDS: Benign paroxysmal positional vertigo, Risk factors, Cardiovascular diseases, Therapy
RIASSUNTO
La vertigine parossistica posizionale benigna (VPPB) è il tipo più comune di vertigine periferica. Frequentemente dopo il primo episodio la VPPB presenta recidive, con un tasso di ricorrenza tra il 15% ed il 50%. Ad oggi non vi è chiarezza sui processi eziopatogenetici che portano al distacco degli otoconi né su quali siano i fattori che rendono la VPPB una patologia recidivante, ma recenti studi epidemiologici hanno evidenziato una possibile associazione con fattori di rischio cardiovascolari. Lo scopo del presente studio (Sesto Senso Survey) è stato quello di valutare nella popolazione italiana, attraverso un'indagine osservazionale, le principali caratteristiche demografiche e cliniche dei pazienti con VPPB (primo episodio o ricorrente), con particolare attenzione ai potenziali fattori di rischio cardiovascolare. L'indagine è stata condotta in 158 centri di Vestibologia in tutta Italia su 2.682 pazienti (età media 59,3 ± 15,0 anni; 39,1 maschi e 60,9% femmine) affetti da VPPB, da gennaio 2013 a dicembre 2014. I risultati hanno mostrato in questi pazienti l'alta prevalenza di fattori di rischio cardiovascolari come ipertensione arteriosa (55,8%), ipercolesterolemia (38,6%) e diabete (17,7%), oltre ad una elevata familiarità per malattie cardiovascolari (49,4%). In un'elevata percentuale di pazienti si è inoltre registrata la presenza di ipoacusia (42,9%), acufeni (41,2%) o entrambi (26,8%). Significativamente correlata agli episodi di recidiva di VPPB è risultata la presenza di ipertensione arteriosa, dislipidemia e comorbidità cardiovascolare accertata (range OR tra 1,84 e 2,31). Rilevanti anche le associazioni con diabete e patologie tiroidee e autoimmuni (range OR tra 1,73 e 1,89). I risultati dell'indagine confermano la significativa associazione tra comorbidità cardiovascolari e VPPB recidivanti e le identificano come importante potenziale fattore di rischio per le recidive di VPPB nella popolazione italiana, aprendo la strada alla valutazione di nuove strategie terapeutiche nel trattamento di questa patologia.
Introduction
Benign paroxysmal positional vertigo (BPPV) is a clinical syndrome characterised by brief recurrent episodes of vertigo, triggered by changes in head position with respect to gravity and due to abnormal stimulation of the cupula of one of the three semicircular canals, most frequently the posterior one. The excitatory response of the cupula is generated by otoliths that detach from the macula of the utricle and move into the lumen of the semicircular canal in response to movements of the head; otoliths then reach the cupula that is stimulated abnormally by the small crystals, thus causing vertigo and nystagmus. Otoliths, which have been observed during surgery, may in some cases adhere to the cupula, generating a form of BPPV called cupulolithiasis 1 2. The characteristic signs of BPPV are evoked when the subject's head is positioned so that the plane of the semicircular canal is aligned with gravity, generating nystagmus and vertigo. The duration, frequency and intensity of symptoms can vary. Autonomic manifestations (nausea, vomiting) or a persistent residual dizziness can be also present 1 2.
BPPV is the most common type of peripheral vertigo, with a reported prevalence of 11 to 64 cases per 100,000 persons, with a peak in the 50-70 age group; a higher prevalence is reported among women 1 3.
BPPV often relapses after the first episode, with a recurrence rate of between 15% and 50%, and the episode usually reoccurs within a few months 1 4.
To date both the aetiopathogenetic processes that lead to otoconia detachment and the factors that make BPPV a recurrent disease are unclear. In recent years, various epidemiological studies have analysed family history data in order to highlight any comorbidities that might be related to recurrences of BPPV 3-6. Between 2007 and 2009, the Revert international registry collected data from over 4000 consecutive cases of vertigo observed in 618 vestibology centres in 13 countries around the world 7. This and other studies demonstrated an association between recurrent BPPV and arterial hypertension (present in 52% of cases), hyperlipidaemia (up to 55% of cases), thyroid dysfunction (up to 21.3% of cases) and a significant prevalence of diabetes in patients with BPPV compared with the general population 4 6 8. In a recent observational study, hypertension and diabetes were shown to be significantly related to risk of recurrent BPPV, with increased risk if both comorbidities were present at the same time 5. The Revert registry showed that 46.3% of BPPV subjects had cardio-vascular comorbidities, and 17.2% hormonal dysfunctions 7. This is consistent with the hypothesis that both arterial hypertension and hyperlipidaemia can cause vascular damage in the inner ear. Furthermore, it is known that BPPV may follow an ischaemic event around the anterior vestibular artery which would facilitate otoconia detachment from the utricle. Additionally, vertebrobasilar ischaemia has been suggested as a predisposing factor for BPPV and some data sustain a correlation between BPPV and stroke 4. A recent retrospective nationwide population study in Taiwan examined data from the National Health Research Institute (NHRI) to assess cerebrovascular risk in patients with BPPV compared with a control group. Over a period of 9 years, the risk of stroke in BPPV subjects was 1.4-fold higher than the risk in subjects without BPPV (p = 0.001) 9.
The aim of the present study was to evaluate in the Italian population, through an observational survey, the main demographic and clinical characteristics of patients with BPPV (first episode or recurrent) with particular focus on potential cardiovascular risk factors.
Materials and methods
Our investigation is a multicentric observational study. We collected patient history and diagnostic and clinical assessments on 2,682 patients who had referred to 158 Italian vestibology out-patient clinics belonging to the "Sesto Senso Study Group" from January 2013 to December 2014. The inclusion criterion was a diagnosis of BPPV, either initial episode or recurrence. We considered recurrent BPPV the new clinical manifestation of vertigo signs and symptoms after the resolution of the previous episode, diagnosed according to the standard practice of each centre.
The data were registered using a form divided into four sections (Fig. 1):
Fig. 1.
Data collection form.
Patient history (possible risk factors): family history of vertigo and cardiovascular disease, vascular and metabolic risk factors (hypertension, hypercholesterolaemia, hypertriglyceridaemia, acute or chronic cerebrovascular disease, acute or chronic cardiovascular disease, diabetes, hyperuricaemia), use of drugs and/ or other comorbidities.
Hearing loss and tinnitus: reported audiological symptoms associated with episodes of BPPV.
Characteristics of BPPV, first episode or recurrence: number and frequency of episodes, canal involved.
Treatment of first BPPV episode and any subsequent episodes: description of the treatment used; in the event of pharmacological treatment, duration of therapy.
The demographic and clinical data were summarised in frequency tables or central tendency and dispersion tables, using the most suitable indicators for the variables (mean, standard deviation).
The discrete data were summarised as absolute frequencies and relative frequency percentages. Missing values were not considered for calculation of the relative frequency percentages.
The analysis of the association between recurrence and possible risk factors was performed through the χ2 test and the odds ratios (OR) with 95% confidence intervals.
Statistical analysis was performed using SPSS Statistical Package, ver. 16.0.
In the event of missing data, no replacement approach was applied.
Results
Demographic data
A total of 2,682 valid forms were collected for statistical processing (Table I).
Table I.
Demographic data.
| Patients | N = 2,682 |
|---|---|
| Gender (n = 2,579) * | n (%) |
| Males | 1008 (39.1%) |
| Females | 1571 (60.9%) |
| Age (n = 2621)† | n (%) |
| Mean (± SD) | 59.3 ± 15.0 |
| Over 65 | 1004 (38.3%) |
| Age groups | |
| < 18 | 6 (0.2%) |
| 18-29 | 84 (3.2%) |
| 30-39 | 204 (7.8%) |
| 40-49 | 418 (15.9%) |
| 50-59 | 486 (18.5%) |
| 60-69 | 698 (26.6%) |
| 70-79 | 535 (20.4%) |
| ≥ 80 | 190 (7.2%) |
103 missing data on gender.
61 missing data on age.
Most patients were women (60.9%). The mean age at diagnosis was 59.3 years (SD ± 15.0), with a percentage of over 65 of 38.3%. The 60-69 age group was the most frequent (26.6%), while only 0.2% were under 18 years of age.
Medical history and comorbidities
The possible risk factors are shown in Table II. 55.8% of patients had high blood pressure and nearly half (49.4%) had a family history of cardiovascular disease. Hypercholesterolaemia and hypertriglyceridaemia were found, respectively, in 38.6% and 21.1% of patients, and diabetes in 17.7%. At anamnesis, 12.3% of the sample reported a previous diagnosis of cardiovascular disease and 12.6% a cerebrovascular disease. The frequency of thyroid pathology was 14.2%; 28% of patients used proton-pump inhibitors and 30% were smokers.
Table II.
Medical history and possible risk factors.
| Family history | n / N (%) |
|---|---|
| Cardiovascular diseases | 1253 / 2538 (49.4%) |
| Vertigo symptoms | 401 / 2318 (17.3%) |
| Risk factors and vascular disorders | |
| Hypertension | 1416 / 2537 (55.8%) |
| Hypercholesterolaemia | 917 / 2377 (38.6%) |
| Hypertriglyceridaemia | 477 / 2266 (21.1%) |
| Cerebrovascular disease (acute or chronic) | 277 / 2196 (12.6%) |
| Cardiovascular disease | 268 / 2185 (12.3%) |
| Metabolic disorders | |
| Diabetes | 419 / 2363 (17.7%) |
| Hyperuricaemia | 72 / 2193 (3.3%) |
| Drugs | |
| Use of proton-pump inhibitors (PPI) | 638 / 2279 (28.0%) |
| Use of ototoxic drugs | 193 / 2122 (9.1%) |
| Other | |
| Headaches and/or migraine | 668 / 2202 (30.3%) |
| Smoker | 665 / 2216 (30.0%) |
| Visual disturbances | 473 / 2163 (22.0%) |
| Cervical hernia | 311 / 2111 (14.7%) |
| Thyroid dysfunction | 298 / 2102 (14.2%) |
| Autoimmune disease | 100 / 2024 (4.9%) |
| Inflammatory and/or autoimmune disease (acute or chronic) | 79 / 1958 (4.0%) |
| Radiotherapy | 71 / 2066 (3.4%) |
| Giant cell arteritis | 37 / 2046 (1.8%) |
| Macroglobulinaemia | 19 / 2022 (0.9%) |
| Cryoglobulinaemia | 8 / 2031 (0.4%) |
| HEARING LOSS | 1131 / 2637 (42.9%) |
| Onset | |
| Before episode of BPPV | 811 / 1010 (80.3%) |
| During episode of BPPV | 115 / 1010 (11.4%) |
| After episode of BPPV | 81 / 1010 (8.0%) |
| Side | |
| Right side | 121 / 1020 (11.9%) |
| Left side | 107 / 1020 (10.5%) |
| Bilateral | 792 / 1020 (77.6%) |
| Type | |
| Conductive | 24 / 929 (2.6%) |
| Mixed | 112 / 929 (12.1%) |
| Sensorineural | 793 / 929 (85.4%) |
| TINNITUS | 1027 / 2494 (41.2%) |
| Onset | |
| Before episode of BPPV | 631 / 902 (69.9%) |
| During episode of BPPV | 156 / 902(17.3%) |
| After episode of BPPV | 115 / 902(12.8%) |
| Side | |
| Right side | 221 / 848 (26.1%) |
| Left side | 184 / 848 (21.7%) |
| Bilateral | 443 / 848 (52.2%) |
| HEARING LOSS and TINNITUS * | 719 (26.8%) |
We considered all patients (n=2682), counting those who answered "Yes" to "Hearing loss" and "Tinnitus".
Hearing loss and tinnitus
In most cases, BPPV was associated with audiological symptoms (Table II). 42.9% of patients presented hearing loss, 80.3% of whom reported onset before the episode of BPPV and 85.4% of cases were of a sensorineural nature. 41.2% of patients had tinnitus, 69.9% of whom reported onset before the episode of BPPV and in 52.2% of cases this was bilateral. 26.8% of the sample presented hearing loss and tinnitus simultaneously. The patients who had hearing loss were older (p < 0.001). In particular, the average age of the patients with hearing loss (n = 1131) was of 66.4 years (SD 12.4), while the average age of patients without hearing loss (n = 1506) was 53.8 years (SD 14.4).
Characteristics of BPPV
The clinical features of BPPV episodes are shown in Table III. A near-uniform distribution was recorded between the first episode of BPPV (47.5%) and recurrent BPPV (52.5%). In terms of the frequency of recurring episodes, 1-5 episodes per year was the most commonly reported range (84.3%), while 15.7% reported 6 or more episodes per year. The canal most commonly involved in the first episode of BPPV was the posterior semicircular canal (57.4%), and most relapses involved the same canal (49.2%).
Table III.
Characteristics of BPPV episodes.
| No. (%) | |
|---|---|
| Patients - BPPV* | 2638 |
| First Episode | 1252 (47.5%) |
| Recurrences | 1386 (52.5%) |
| Other episodes in the last twelve months (< 12 months) | 781 (56.4%) |
| Other episodes prior to the last 12 months (> 12 months) | 326 (23.5%) |
| Other episodes both in the last 12 months and prior to the last 12 months | 279 (20.1%) |
| Frequency of BPPV recurrence in the last 12 months† | |
| 1 to 5 episodes | 840 (84.3%) |
| 6 to 9 episodes | 101 (10.1%) |
| More than 9 episodes | 56 (5.6%) |
| Canal affected in the first episode of BPPV‡ | |
| The posterior semicircular canal (PSC) | 1356 (57.4%) |
| The lateral semicircular canal (LSC) geotropic variant | 681 (28.8%) |
| The lateral semicircular canal (LSC) apogeotropic variant | 214 (9.1%) |
| Other forms of labyrinth lithiasis | 112 (4.7%) |
| Canal affected in subsequent BPPV episodes | |
| Same canal | 682 / 1386 (49.2%) |
44 missing data for BPPV features.
63 missing data for number of BPPV episodes in the 1060 (781 + 279) patients who reported episodes in the last twelve months.
319 missing data for canal affected in the first episode of BPPV
Treatment of vertigo
The treatment of BPPV, reported in Table IV, is based on rehabilitative manoeuvres (85.9%), followed by vasoactive drugs (35.9%). Use of antivertigo drugs was found in roughly one-third of the total sample (32.7%). Only in 4.4% of cases were central nervous system (CNS) depressants used.
Table IV.
Treatment of BPPV.
| No. (%) | |
|---|---|
| Treatment used for BPPV episodes | |
| Rehabilitative manoeuvres | 2305 (85.9%) |
| Antivertigo drugs | 878 (32.7%) |
| Vasoactive drugs | 964 (35.9%) |
| CNS depressants | 118 (4.4%) |
| Total patients treated with drugs* | 1571 (58.6%) |
| Duration of drug therapy† | |
| 1 to 2 months | 841 (64.7%) |
| 3 to 6 months | 390 (30.0%) |
| 7 to 9 months | 26 (2.0%) |
| 9 to 12 months | 43 (3.3%) |
365 out of 1,571 (23.2%) patients used more than one drug.
Of the 1,571 patients with prescribed medications, 271 had missing data for "Duration of drug therapy."
In most cases, medical treatment lasted between 1 and 2 months (64.7%), while in about one-third of patients (30%) it was 3-6 months and only in 5.3% of cases did treatment continue for over 6 months.
Association between recurrence and comorbidities
In addition to the descriptive research, statistical processing of the data was performed in order to analyse the association between recurrent BPPV and possible risk factors (Table V, Fig. 2). The following significant correlations were found: family history of vertigo associated with cardiovascular disease (OR = 1.5, p < 0.001 and OR = 1.46, p < 0.005), hypertension (OR = 2.05, p < 0.001), hypercholesterolaemia (OR = 1.84, p < 0.001), hypertriglyceridaemia (OR = 2.11, p < 0.001), cerebrovascular disease (OR = 1.88, p < 0.001) and cardiovascular disease (OR = 2.31, p < 0.001). In addition, the association with diabetes was significant (OR = 1.73, p < 0.001). Finally, a correlation with the use of proton-pump inhibitors and with the use of ototoxic drugs was also found (OR 1.81, p < 0.001 and OR 1.96, p < 0.001, respectively).
Table V.
Association between the first episode of BPPV or recurrent BPPV and comorbidities, drugs and lifestyles.
| BPPV | Crude OR | CI 95% | p (*) | ||
|---|---|---|---|---|---|
| Patients at first episode | Patients with recurrences | ||||
| Family history | |||||
| Cardiovascular diseases | 526 (44.1%) | 715 (54.7%) | 1.54 | 1.31-1.80 | < 0.001 |
| Dizziness symptoms | 159 (14.6%) | 239 (20.0%) | 1.46 | 1.17-1.82 | < 0.005 |
| Risk factors and vascular disorders | |||||
| Hypertension | 557 (46.9%) | 844 (64.4%) | 2.05 | 1.75-2.41 | < 0.001 |
| Hypercholesterolaemia | 348 (31.2%) | 558 (45.5%) | 1.84 | 1.55-2.18 | < 0.001 |
| Hypertriglyceridaemia | 157 (14.8%) | 314 (26.8%) | 2.11 | 1.70-2.61 | < 0.001 |
| Cerebrovascular disease (acute or chronic) | 96 (9.2%) | 178 (15.9%) | 1.88 | 1.44-2.45 | < 0.001 |
| Cardiovascular disease | 82 (7.9%) | 183 (16.5%) | 2.31 | 1.76-3.05 | < 0.001 |
| Metabolic disorders | |||||
| Diabetes | 152 (13.6%) | 261 (21.5%) | 1.73 | 1.39-2.16 | < 0.001 |
| Hyperuricaemia | 24 (2.3%) | 47 (4.2%) | 1.86 | 1.13-3.06 | < 0.05 |
| Drugs | |||||
| Use of proton-pump inhibitors (PPI) | 234 (21.9%) | 396 (33.7%) | 1.81 | 1.50-2.19 | < 0.001 |
| Use of ototoxic drugs | 63 (6.2%) | 124 (11.5%) | 1.96 | 1.43-2.69 | < 0.001 |
| Other | |||||
| Visual disturbances | 180 (17.9%) | 288 (25.6%) | 1.59 | 1.29-1.96 | < 0.001 |
| Headaches and/or migraine | 279 (27.0%) | 377 (33.1%) | 1.34 | 1.12-1.61 | < 0.01 |
| Cervical hernia | 122 (12.4%) | 187 (17.0%) | 1.44 | 1.13-1.84 | < 0.025 |
| Radiotherapy | 35 (3.6%) | 36 (3.4%) | 0.93 | 0.58-1.45 | ns |
| Smoker | 316 (30.3%) | 338 (29.6%) | 0.97 | 0.81-1.16 | ns |
| Giant cell arteritis | 24 (2.5%) | 13 (1.2%) | 0.49 | 0.25-0.97 | < 0.05 |
| Cryoglobulinaemia | 4 (0.4%) | 4 (0.4%) | 0.92 | 0.23-3.69 | ns |
| Macroglobulinaemia | 8 (0.8%) | 10 (1.0%) | 1.17 | 0.45-2.94 | ns |
| Thyroid disfunction | 118 (11.9%) | 174 (16.1%) | 1.42 | 1.10-1.82 | < 0.025 |
| Autoimmune disease | 35 (3.7%) | 63 (6.0%) | 1.68 | 1.10-2.57 | < 0.05 |
| Inflammatory and/or autoimmune disease (acute or chronic) | 26 (2.8%) | 52 (5.2%) | 1.89 | 1.17-3.04 | < 0.05 |
Crude Odds Ratio (OR) and 95% Confidence Intervals (95%) and their p-values.
χ2 Test.
Fig. 2.
Association between recurrent BPPV and comorbidities, medications, lifestyles: Crude OR and 95% Confidence Intervals.
Discussion
To date it is still unclear what is the aetiopathogenetic mechanism of BPPV and whether there are any other diseases related to the recurrence of BPPV. Recent epidemiological studies have shown a possible association with cardiovascular risk factors 3 5-7 9.
In the present observational study, cardiovascular history was assessed for 2,682 patients diagnosed with BPPV, both initial episodes and recurrences, who had referred to 158 Italian vestibology out-patient clinics from January 2013 to December 2014. Most patients were over 40 years old (88.6%), with a prevalence of women (60.9%) and a BPPV recurrence rate of 52.5%, in line with data reported in literature 1 3. With regards to the prevalence of recurrent BPPV, only the Ogun et al. survey conducted in the United States has until now registered a higher frequency (76.3%), but this, as reported by the authors, may be due to the survey procedures used which favoured selection of patients with recurrent BPPV 6.
Our survey showed a high prevalence of cardiovascular risk factors such as high blood pressure (55.8%), hypercholesterolaemia (38.6%) and diabetes (17.7%), as well as family history of cardiovascular disease (49.4%). A comparison of the relative frequencies of these risk factors in the study sample with the data available for the general population highlighted the higher prevalence of these parameters in patients with BPPV vs. the general population (Fig. 3) 10.
Fig. 3.
Prevalence of vascular risk factors in the study sample and the general population.
A high proportion of patients had hearing loss and/or tinnitus (up to 42.9%), a result consistent with Ogun et al. study in which 41.9% of subjects displayed hearing loss, suggesting that audiological symptoms in BPPV patients are potential markers of vascular pathophysiology in the inner ear that should be validated 11.
Analysis of correlations also suggests that cardiovascular risk factors expose the BPPV subject to a risk of relapse with OR values that sometimes are higher than 2. Specifically, the presence of arterial hypertension, dyslipidaemia and established cardiovascular comorbidities (OR range between 1.84 and 2.31) would seem to be significantly related to episodes of recurrent BPPV, and association with diabetes and thyroid/autoimmune disease (OR range between 1.42 and 1.89) would seem to be relevant.
These results support the hypothesis of a vascular role in the aetiopathogenesis of BPPV and its recurrence. Moreover, the link between inflammation and vascular pathophysiology of the inner ear and audio-vestibular disorders has already been pointed out 10-13. As is known, the blood supply to the inner ear is a terminal circulation and given the lack of collateral circulation, any even partial occlusion of the AICA (anterior inferior cerebellar artery) or VBA (vertebrobasilar artery) can cause an ischaemic event in the inner ear 11. Recently, patients with idiopathic sudden hearing loss were shown to have significantly lower flow-mediated dilation of the brachial artery than controls (5.6 ± 1.6 vs. 7.7 ± 3.7; p < 0.01) 14, significantly lower levels (p = 0.018) of endothelial progenitor cells 15 and increased plasma levels of adhesion molecules, which is an early sign of endothelial dysfunction 16.
The data have also suggested an unexpected correlation between the recurrence of BPPV and use of proton-pump inhibitors, and confirmed a possible correlation between recurrence of BPPV and the use of ototoxic drugs. These data stimulate further specific studies.
Finally, it is interesting to note that in our sample more than 80% of patients reported hearing loss or tinnitus prior to the episode of BPPV. At the same time, it should also be underlined the fact that patients with hearing loss were significantly older. For these reasons, and given the importance of the issue, to evaluate the possible correlation between hearing loss and BPPV it would be necessary in the future perform a specific study, which evaluates in detail the various characteristics of the hearing loss in BPPV for classes of age and comparing such data with an adequate sample of subjects not suffering from BPPV.
The survey results also suggests some considerations regarding therapeutic strategies adopted in the treatment of BPPV. Standard treatment generally involves rehabilitation therapy based on liberatory or repositioning manoeuvres that are effective in resolving symptoms in up to 90% of cases within 24 hours 17. However, the number of manoeuvres needed to achieve resolution can vary and the incidence of residual dizziness after treatment is high (60%) and long-term (13-16 days), thus complicating complete resolution of symptoms 18 19. The use of vasoactive drugs could therefore be of help, especially to contrast any pathogenetic mechanism with a microcirculatory component. Specifically, treatment could include not only drugs to reduce the impact of known risk factors (antihypertensives, statins, antidiabetics) but also more specific vascular drugs to counteract "causal" damage generated on the endothelial wall in the inner ear, such as glycosaminoglycans (GAGs), which exert anti-inflammatory and antithrombotic actions on the endothelial wall 10 20-24. In this regard, our study showed that antivertigo drugs were prescribed in almost 33% of cases and vasoactive drugs in about 36%, thus demonstrating that specialists are aware of vascular risk factors.
Our study has some limitations. For example, many parameters have not been evaluated, including brain MRI, post-traumatic vertigo and psychiatric disorders. Furthermore, the study did not have an appropriate control of the population without BPPV. Finally, the observational nature of the study, obviously, did not allow definitive answers about the investigated correlations, which require appropriate studies, but that nonetheless gave, albeit partial, a significant picture of the Italian real-life situation on BPPV helping to increase knowledge about the comorbidity in BPPV also investigated recently in other studies 25-27.
Conclusions
In conclusion, the present study investigated the demographic and clinical characteristics of 2,682 Italian patients with BPPV. In particular, the results have highlighted a population of patients with 60 years on average, a prevalence of women (60.9%) and a high BPPV recurrence rate (52.5%). Finally, the study seems to confirm the prevalence of cardiovascular comorbidities in patients suffering from BPPV and identify them as potential important risk factors for recurrent BPPV in the Italian population, paving the way for the evaluation of new therapeutic strategies.
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