Evaluation and Management of Orthostatic Hypotension

Diagnostic Approach

The American Heart Association defines orthostatic hypotension as a sustained drop of ≥20 mmHg systolic or ≥10 mmHg diastolic blood pressure within 3 minutes of standing 3, 4, 5, 1
Measure blood pressure after 5 minutes of lying supine, then at 1 minute AND 3 minutes after standing to capture both immediate and delayed orthostatic hypotension 1, 2
Monitor heart rate response during position change: a heart rate increase <15 bpm suggests neurogenic orthostatic hypotension (autonomic dysfunction), while ≥15 bpm suggests non-neurogenic causes 1, 2

The American College of Cardiology recommends administering acute water ingestion (≥240 mL, preferably ≥480 mL) for temporary relief, with peak effect at 30 minutes 3, 4, 5
Position the patient supine or seated immediately to relieve symptoms and prevent injury from falls 2

Increase fluid intake to 2-3 liters daily 2
Encourage increased salt intake (6-9 grams or 1-2 teaspoons per day) to expand plasma volume, but avoid in patients with hypertension, renal disease, or heart failure 3, 4, 5
Teach leg crossing, squatting, lower body muscle tensing, and maximal force handgrip to acutely raise blood pressure when symptoms occur 3, 4, 5, 1, 2

Midodrine is the preferred first-line agent for symptomatic orthostatic hypotension that persists despite non-pharmacologic interventions 2
The goal of midodrine treatment is to improve symptoms and functional capacity, not to achieve arbitrary blood pressure targets 2
Fludrocortisone (0.1-0.3 mg daily) increases plasma volume but should be avoided when supine hypertension is present 3, 4, 5

Prioritize identifying and treating reversible causes before considering chronic pharmacologic therapy in young patients (18 years) 6, 1, 2
Dehydration is the most likely culprit and should be addressed with oral or intravenous fluid resuscitation 6