history and examination - the key feature of symptoms related to orthostatic hypotension is that they are precipitated by head-up postural change and relieved by lying flat. Other factors may influence symptoms e.g. speed of positional change, coughing. There may be a history of impairment of other organs under autonomic control e.g. lack of sweating suggests a neurogenic cause. A detailed drug history should be taken
the differential diagnosis includes carotid sinus syncope
Carotid sinus syndrome
causes syncope, near-syncope, or unexplained falls due to carotid sinus hypersensitivity
like postural hypotension, it is more common in older people and is difficult to distinguish clinically
tilt-table testing may help in a diagnosis - this is undertaken via a specialist e.g. cardiologist
degree of orthostatic hypotension should be determined by measurement of blood pressure and heart rate whilst the patient is lying flat and either standing upright or at a 45 degree angle
investigations include:
blood tests - full blood count if the patient has chronic bleeding or anaemia, urea and electrolytes, HbA1c for diabetes, vitamin B12
ECG - if an arrythmia is suspected
echo - if a structural heart problem is suspected
referral to a specialist if symptoms are not controlled or are persistent and frequent, or if the cause is unexplained
consideration of specialist referral is based on the patient's age, symptoms, and medical conditions
for example
a young patient with repeated unexplained syncopal symptoms and palpitations would be referred to a cardiologist
an older patient with bradykinesia and a shuffling gait would be referred to a neurologist, and an elderly frail patient with multimorbidity and polypharmacy with recurrent falls would be referred to a geriatrician (2)
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