Management of Orthostatic Hypotension

Diagnosis and Assessment

The American College of Cardiology recommends confirming orthostatic hypotension by a sustained drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing 1, 4
The European Heart Journal suggests measuring blood pressure and heart rate after 5 minutes lying down, then at 1 minute and 3 minutes after standing to confirm orthostatic hypotension 1, 2, 3
A heart rate increase <15 bpm upon standing indicates autonomic nervous system dysfunction, characteristic of neurogenic orthostatic hypotension 1, 5
A heart rate increase ≥15 bpm upon standing suggests non-neurogenic orthostatic hypotension, which may be caused by medications, dehydration, blood loss, or cardiac dysfunction 5

The European Heart Journal recommends positioning the patient supine or seated immediately to relieve symptoms and prevent syncope or falls 2, 3
Increasing fluid intake to 2-3 liters daily can help alleviate orthostatic hypotension symptoms 5
Teaching acute physical counterpressure maneuvers, such as leg crossing, squatting, arm tensing, and bending forward at the waist, can help raise blood pressure when symptoms occur 1, 5

Midodrine is the preferred first-line pharmacologic agent for symptomatic orthostatic hypotension that persists despite nonpharmacologic interventions 5
The goal of midodrine treatment is to improve symptoms and functional capacity, not to achieve arbitrary blood pressure targets 5

The American College of Cardiology recommends monitoring for supine hypertension in patients with autonomic failure, as it can lead to left ventricular hypertrophy, coronary disease, and other complications 5
Orthostatic hypotension carries a 64% increase in age-adjusted mortality and increased risk of falls and fractures in the elderly 6
Delayed orthostatic hypotension is common in elderly persons due to stiffer hearts and impaired compensatory vasoconstrictor reflexes 2, 3