Management of Orthostatic Hypotension

Diagnosis and Assessment

The American College of Cardiology recommends measuring blood pressure after 5 minutes of lying or sitting, then at 1 and 3 minutes after standing—a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic confirms orthostatic hypotension 1, 2
Document symptoms during testing: dizziness, lightheadedness, blurred vision, weakness, or syncope indicate symptomatic orthostatic hypotension requiring treatment 1

Increase fluid intake to 2-3 liters daily unless contraindicated by heart failure, as recommended by the American Heart Association 1
Increase salt consumption to 6-9 grams daily if not contraindicated—use liberalized dietary sodium rather than salt tablets to minimize gastrointestinal side effects, according to the European Society of Cardiology 1, 3
Teach leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes—these maneuvers are particularly effective in patients under 60 years with prodromal symptoms, as suggested by the American Autonomic Society 1

Midodrine has the strongest evidence base among pressor agents, with three randomized placebo-controlled trials demonstrating efficacy, according to the American College of Cardiology 1
The starting dose of midodrine is 2.5-5 mg orally three times daily, with titration individually tailored up to 10 mg three times daily based on response, as recommended by the European Society of Cardiology 1
Fludrocortisone is an alternative or addition for refractory cases, with a starting dose of 0.05-0.1 mg once daily and titration individually adjusted to 0.1-0.3 mg daily based on response, according to the American Heart Association 1

For patients with concurrent hypertension and orthostatic hypotension, long-acting dihydropyridine calcium channel blockers or RAS inhibitors are first-line therapy, as recommended by the American College of Cardiology 1
Older adults (≥85 years) with frailty should have blood pressure-lowering treatment deferred until office BP ≥140/90 mmHg, with a target of "as low as reasonably achievable" (ALARA principle) rather than strict 130/80 mmHg, according to the European Society of Cardiology 1