Management of Orthostatic Hypotension

Initial Assessment and Classification

Neurogenic orthostatic hypotension is characterized by a heart rate increase of less than 15 bpm upon standing, indicating autonomic nervous system dysfunction, according to the American College of Cardiology 1
Non-neurogenic orthostatic hypotension is characterized by an adequate heart rate increase of 15 bpm or more, suggesting causes such as medications, dehydration, blood loss, or cardiac dysfunction, as stated by the American Heart Association 1
The distinction between neurogenic and non-neurogenic orthostatic hypotension is critical because neurogenic forms often require more aggressive pharmacologic management and carry a risk of supine hypertension, as noted by the European Society of Cardiology 2

Increasing fluid intake to 2-3 liters daily is recommended for all patients with orthostatic hypotension, according to the American College of Cardiology 3
Avoiding large meals that can worsen postprandial hypotension is recommended, as stated by the American Heart Association 1
Limiting or avoiding alcohol is recommended, as noted by the European Society of Cardiology 2
Teaching patients acute maneuvers to raise blood pressure when symptoms occur, such as leg crossing, squatting, arm tensing, and bending forward at the waist, is recommended, according to the American College of Cardiology 1

Midodrine is the preferred first-line pharmacologic agent for symptomatic orthostatic hypotension that persists despite nonpharmacologic interventions, as stated by the American Autonomic Society 1
The goal of treatment is to improve symptoms and functional capacity, not to achieve arbitrary blood pressure targets, according to the European Society of Cardiology 2
Measuring supine and standing blood pressures at each visit is recommended to assess treatment response and detect supine hypertension, as noted by the American College of Cardiology 1

Supine hypertension in autonomic failure patients is a critical pitfall to avoid, as it can lead to left ventricular hypertrophy, coronary disease, flash pulmonary edema, heart failure, renal failure, stroke, and sudden death, as noted by the European Society of Cardiology 2
Pseudohypertension in elderly patients is another critical pitfall to avoid, as it can lead to inadvertently overdosing with antihypertensives and causing symptomatic orthostatic hypotension, according to the American Geriatrics Society 2