Management of Orthostatic Hypotension

Diagnosis and Assessment

The diagnosis of orthostatic hypotension is confirmed by measuring blood pressure after 5 minutes of lying/sitting, then at 1 and 3 minutes after standing, with a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic, or ≥30 mmHg systolic drop in patients with baseline hypertension 1, 2
Assess heart rate response during postural change to distinguish neurogenic from non-neurogenic causes, with a blunted heart rate increase (<10 bpm) suggesting neurogenic orthostatic hypotension 2, 3

Discontinue or switch medications that worsen orthostatic hypotension, such as alpha-1 blockers, diuretics, vasodilators, and centrally acting agents, rather than simply reducing doses 1, 2
Switch to long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line antihypertensive agents in patients with concurrent hypertension and orthostatic hypotension 1

Increase fluid intake to 2-3 liters daily and salt intake to 6-9 grams daily, unless contraindicated by heart failure 1
Teach physical countermeasures such as leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes 1
Use compression garments such as waist-high compression stockings (30-40 mmHg) and/or abdominal binders to reduce venous pooling 1, 3

Midodrine is the first-line medication with the strongest evidence base, starting at 2.5-5 mg three times daily and titrating to 10 mg three times daily as needed, with the last dose at least 3-4 hours before bedtime 1
Fludrocortisone may be used as an alternative or in combination with midodrine, starting at 0.05-0.1 mg once daily and titrating to 0.1-0.3 mg daily, with monitoring for supine hypertension and hypokalemia 1, 2
Droxidopa may be used in patients with neurogenic orthostatic hypotension, particularly in those with Parkinson's disease, pure autonomic failure, and multiple system atrophy 1, 2

In patients with diabetes and autonomic neuropathy, assess for cardiovascular autonomic neuropathy and expect a neurogenic pattern, with midodrine or droxidopa preferred as "norepinephrine replacers" 1, 2
In patients with Parkinson's disease, review antiparkinsonian medications as potential contributors and consider droxidopa as a treatment option 1, 3
In frail elderly patients (≥85 years), defer blood pressure-lowering treatment until office BP ≥140/90 mmHg and use "as low as reasonably achievable" (ALARA) principle rather than strict targets 1

Initial follow-up within 1-2 weeks after medication changes, with measurement of both supine and standing blood pressure, orthostatic vital signs, and assessment of symptom improvement and functional capacity 1
Ongoing assessment of orthostatic vital signs, symptom diary, falls assessment, and quality of life and functional status 1, 2, 3

Patients aged ≥ 50 years with hypertension should have both supine (or sitting) and standing blood‑pressure measurements obtained periodically at routine visits. (Hypertension guideline, 2003) 4
Elderly individuals, patients on antihypertensive or diuretic therapy, those with Parkinson’s disease, autonomic neuropathy, or recent syncope, and anyone after a medication change that may affect vascular tone should undergo orthostatic blood‑pressure assessment at every routine visit, with a mandatory reassessment 1–2 weeks after the change. (Hypertension guideline, 2003) 4

When a new antihypertensive, diuretic, or any drug influencing vascular tone is started or its dose is altered, clinicians should repeat orthostatic measurements (both supine and standing) within 1–2 weeks to detect treatment‑related orthostatic effects. (European Society of Cardiology recommendation, 2018) 5

Any patient who presents with syncope, presyncope, unexplained falls, dizziness, light‑headedness, or postural unsteadiness must receive an immediate orthostatic blood‑pressure assessment. (European Society of Cardiology recommendation, 2018) 5

After a syncopal episode, orthostatic blood‑pressure measurements should be repeated at follow‑up visits for at least six months, because the risk of recurrence remains elevated during this period. (European Society of Cardiology recommendation, 2018) 5

Clinicians should first exclude reversible contributors such as volume depletion, medication effects, or other treatable conditions before diagnosing orthostatic hypotension as a manifestation of autonomic failure. (European Society of Cardiology recommendation, 2018) 5