Causes of Persistent Hypotension

The American College of Cardiology notes that medications are the most common reversible cause of persistent hypotension and should be systematically reviewed in every patient 1, 2
Antihypertensive agents, including diuretics, ACE inhibitors, ARBs, vasodilators, and centrally acting agents, are frequent culprits 1, 3
Excessive diuresis leading to volume contraction increases the risk of hypotension with ACE inhibitors and vasodilators 1
Psychotropic medications, including tricyclic antidepressants, phenothiazines, and monoamine oxidase inhibitors, cause significant orthostatic hypotension 4, 3
NSAIDs and COX-2 inhibitors can block diuretic effects and contribute to fluid retention or hypotension 1

Cardiovascular Causes

The American College of Cardiology recommends immediate assessment of cardiac dysfunction and volume depletion as critical reversible causes of hypotension 2, 3, 5
Heart failure with reduced ejection fraction (HFrEF) causes decreased cardiac output 2, 3, 5
Cardiogenic shock is defined as systolic BP <90 mmHg for >30 minutes despite adequate volume with signs of hypoperfusion 5
Myocardial depression is common in septic shock 2
Volume depletion from dehydration, bleeding, or excessive diuresis contributes to hypotension 3, 5

In septic and distributive shock, hypotension results from vasoplegia with variable cardiac output, according to the Intensive Care Medicine journal 2
Septic shock is characterized by vasoplegia, shunting, decreased oxygen extraction, and low, normal, or high cardiac output 2
Pancreatitis and other inflammatory states can cause distributive shock 2

The Circulation journal notes that specific drug overdoses require targeted management approaches 4
Calcium channel blocker toxicity causes myocardial depression and vasodilation 4
Beta-blocker toxicity causes bradycardia and decreased contractility 4
Tricyclic antidepressant overdose is characterized by sodium channel blockade 4
Cocaine toxicity causes coronary vasospasm 4

Excessive concern about mild hypotension or azotemia can lead to underutilization of necessary diuretics and persistent volume overload, according to the Journal of the American College of Cardiology 1
Failure to recognize polypharmacy as a contributing factor, particularly in elderly patients, is a common pitfall 3