Treatment of Persistent Hypotension

Initial Assessment and Reversible Causes

The European Society of Cardiology recommends measuring blood pressure in both supine and standing positions to identify orthostatic hypotension (drop of ≥20 mmHg systolic and/or ≥10 mmHg diastolic within 3 minutes of standing) 1
The American Heart Association suggests using ambulatory blood pressure monitoring to identify hypotensive episodes that correlate with symptoms 1
Document neurological status and assess for signs of end-organ hypoperfusion including altered mental status, decreased urine output, rising lactate, and worsening acidosis, as recommended by the American Stroke Association 4, 5
Discontinue or reduce non-heart failure antihypertensive drugs including calcium channel blockers, centrally acting antihypertensive agents, and alpha-blockers, as advised by the European Society of Cardiology 1

The Society of Critical Care Medicine recommends norepinephrine as the initial vasoactive drug after appropriate fluid resuscitation in distributive shock 2
The American College of Cardiology suggests using inotropes (dobutamine, dopamine, or phosphodiesterase III inhibitors) as first-line agents in acute heart failure, with norepinephrine added for persistent hypotension with tachycardia 2
For heart failure with reduced ejection fraction (HFrEF), the European Society of Cardiology recommends initiating SGLT2 inhibitors and mineralocorticoid receptor antagonists first, as they have the least effect on blood pressure but rapid beneficial effects 1

Target mean arterial pressure of at least 65 mmHg in septic shock and distributive shock, as recommended by the Society of Critical Care Medicine 2
Monitor serial markers of systemic and organ perfusion: lactate, mixed or central venous oxygen saturations, urine output, skin perfusion, renal and liver function tests, mental status, as advised by the Society of Critical Care Medicine 2

The American College of Cardiology advises against discontinuing vasopressors too rapidly, as this can lead to hemodynamic collapse in cardiogenic shock 6
Avoid excessive fluid administration in patients with cardiomyopathy, as this worsens cardiac function, as recommended by the American College of Cardiology 6
Recognize that polypharmacy is a common contributing factor, particularly in elderly patients, as noted by the European Society of Cardiology 3