Diagnostic Criteria and Assessment of Orthostatic Hypotension

Definition and Diagnostic Thresholds

Orthostatic hypotension is defined by a systolic blood‑pressure drop ≥ 20 mm Hg or a diastolic drop ≥ 10 mm Hg within 3 minutes of standing from a supine position, or by an absolute systolic pressure < 90 mm Hg within 3 minutes regardless of the magnitude of the fall. (American College of Cardiology; European Society of Cardiology; American Heart Association) 1
In patients with supine hypertension, the diagnostic systolic‑pressure‑drop threshold is increased to ≥ 30 mm Hg. (European Society of Cardiology) 2

After the patient has rested supine for at least 5 minutes, measure blood pressure again at 1 minute and at 3 minutes after standing. (European Society of Cardiology; American Heart Association) 3
Measurements may be obtained during active standing or during head‑up tilt of at least 60°. (European Society of Cardiology) 4
For individuals who cannot stand safely, head‑up tilt table testing at ≥ 60° is recommended. (European Society of Cardiology) 4

Defined by a transient systolic drop > 40 mm Hg and/or diastolic drop > 20 mm Hg within 15 seconds of standing, with spontaneous return to baseline within 40 seconds. (American College of Cardiology; European Society of Cardiology) 1
Although brief, this subtype can still cause syncope. (European Society of Cardiology) 5

Characterized by a sustained reduction of ≥ 20 mm Hg systolic or ≥ 10 mm Hg diastolic within 3 minutes of standing; it is the most commonly recognized form used in clinical practice. (American College of Cardiology; European Society of Cardiology) 1
Symptoms are more related to the absolute blood‑pressure level than to the magnitude of the fall. (European Society of Cardiology) 4

Meets the standard orthostatic criteria (≥ 20/10 mm Hg) but the drop occurs after more than 3 minutes of standing. (American College of Cardiology; European Society of Cardiology) 1
Presents as a slow, progressive blood‑pressure decline, often without accompanying bradycardia; it is common in older adults and may indicate early autonomic failure. (European Society of Cardiology) 4

In neurogenic orthostatic hypotension, the orthostatic heart‑rate increase is blunted (typically < 10 beats/min) because autonomic control is impaired. (European Society of Cardiology) 3
In hypovolemic orthostatic hypotension, the heart‑rate response is preserved or exaggerated. (European Society of Cardiology) 4
Recognizing the heart‑rate pattern is clinically important for identifying the underlying cause and guiding treatment. (European Society of Cardiology) 5

Orthostatic hypotension is associated with increased mortality and a higher risk of cardiovascular disease, stroke, falls, and dementia, even when patients are asymptomatic. (European Society of Cardiology) 3

In elderly patients presenting with dizziness on standing, clinicians should explicitly record whether symptoms such as lightheadedness, visual blurring, or weakness occur concurrently with the measured orthostatic blood‑pressure drop. This documentation helps confirm orthostatic hypotension and guides subsequent management decisions. 6