Management of Orthostatic Hypotension
Assessment and Diagnosis
- Orthostatic hypotension is defined as a decrease in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg within 3 minutes of standing, and should be confirmed by measuring blood pressure after 5 minutes of rest in sitting/lying position, followed by measurements at 1 and 3 minutes after standing 1, 2
- Correlate symptoms with BP measurements to determine if the patient has symptomatic hypotension 3
Address Underlying Causes and Optimize Current Medications
- Significantly elevated TSH on amiodarone is a critical factor to address first, as hypothyroidism can contribute to orthostatic hypotension 1
- Consider spacing out cardiovascular medications to reduce synergistic hypotensive effects 4
- Evaluate if any heart failure medications can be adjusted to improve orthostatic tolerance while maintaining cardiac benefits 5
Non-Pharmacological Interventions
- Continue compression stockings and abdominal binder, which are effective first-line interventions 4, 6
- Consider gradual, supervised exercise training which can improve orthostatic tolerance 4
Special Considerations for Heart Failure
- In patients with heart failure and orthostatic hypotension, SGLT2 inhibitors and MRAs have the least impact on BP and should be continued if possible 4, 5
- For patients with heart failure with preserved ejection fraction (HFpEF), careful medication adjustment rather than discontinuation is preferred 5
- Monitor for worsening heart failure symptoms when adjusting antihypertensive medications 7