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Orthostatic hypotension: clinical review and case study

14 May 2020
Volume 29 · Issue 9


Transient loss of consciousness (TLOC) accounts for 3% of all attendance in emergency departments within the UK. More than 90% of TLOC presentations are due to epileptic seizures, psychogenic seizures or syncope. However, in England and Wales in 2002, it was estimated that 92 000 patients were incorrectly diagnosed with epilepsy, at an additional annual cost to the NHS of up to £189 million. This article will reflect on the case study of a 54-year-old female patient who presented with a possible TLOC, and had a background of long-term depression. Differential diagnoses will be discussed, but the article will focus on orthostatic hypotension. Being diagnosed with this condition is independently associated with an increased risk of all-cause mortality. Causes of orthostatic hypotension and the pathophysiology behind the condition will be discussed, highlighting the importance of obtaining an accurate clinical history. This is extremely pertinent if a patient collapses in an NHS setting and this is witnessed by nurses because they can contribute to the history of the type of collapse, to aid diagnosis and correct treatment. In addition, nurses have a valuable role to play in highlighting polypharmacy to doctors, and non-medical prescribers, as a contributing factor to orthostatic hypotension is polypharmacy. It is therefore important to accurately distinguish TLOC aetiology, not only to provide appropriate management, but to also identify patients at risk of morbidity/mortality related to underlying disease.

This case study will reflect upon presenting dizziness and possible transient loss of consciousness (TLOC) in a 54-year-old female patient (Ms Grey—not her real name) with a background of long-term depression (Table 1). Following determination that the TLOC was non-traumatic and syncopal in nature (Brignole et al, 2018), differentials considered were reflex syncope, which is a brief loss of consciousness due to a drop in blood pressure from a neurological cause, such as a vagsovagal, orthostatic hypotension, arrhythmia or other cardiovascular cause (Japp and Robertson, 2018; National Institute for Health and Care Excellence (NICE), 2014). A detailed record of the event, clinical history and examination including 12-lead electrocardiogram (ECG) (NICE, 2014) was conducted. No cardiac red flags were identified from the ECG, ruling out differentials of arrhythmia and other cardiac aetiologies (Seller and Symons, 2012; Japp and Robertson, 2018). A diagnosis of orthostatic hypotension (OH) was confirmed by a drop of systolic blood pressure greater than (>) 20mmHg and diastolic blood pressure >10mmHg within 3 minutes of standing (Freeman et al, 2011). The most likely underlying cause of OH in this case was considered to be iatrogenic (Gugger, 2011; Seller and Symons, 2012). Management of presenting OH was successfully treated through pharmacological optimisation (Freeman et al, 2011).

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