Management of Orthostatic Hypotension

Diagnosis and Assessment

Orthostatic hypotension is defined as a decrease in systolic blood pressure of ≥20 mm Hg or diastolic blood pressure of ≥10 mm Hg within 3 minutes of standing from a supine or seated position, according to the American Heart Association, as published in Circulation 2
Initial assessment should include measurement of blood pressure after 5 minutes of lying/sitting and then at 1 and/or 3 minutes after standing to confirm the diagnosis, as recommended by Praxis Medical Insights 1
Evaluate for reversible causes including medication effects, volume depletion, and endocrine disorders, as suggested by Praxis Medical Insights 1

Increase fluid intake to 2-3 liters daily and salt consumption to 6-9g daily if not contraindicated by other conditions, as recommended by Praxis Medical Insights 1
Implement physical counter-maneuvers during symptom onset, such as leg-crossing, muscle tensing, squatting, and stooping, as suggested by Praxis Medical Insights 1
Recommend smaller, more frequent meals to reduce post-prandial hypotension, as advised by Praxis Medical Insights 1
Advise acute water ingestion (≥480 mL) for temporary relief, with peak effect occurring 30 minutes after consumption, as recommended by Praxis Medical Insights 1
Recommend compression garments, including thigh-high stockings and abdominal compression, as suggested by Praxis Medical Insights 1
Suggest gradual staged movements with postural change to minimize symptoms, as advised by Praxis Medical Insights 1
Elevate the head of the bed during sleep to help prevent supine hypertension, as recommended by Praxis Medical Insights 1

Modify or discontinue hypotensive drug treatment for concomitant conditions, as recommended by the European Society of Cardiology, as published in the European Heart Journal 3
Consider long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line therapy for patients with both hypertension and orthostatic hypotension, as suggested by Praxis Medical Insights 1
Avoid taking the last dose of any pressor agent after 6 PM to prevent supine hypertension during sleep, as advised by Praxis Medical Insights 1

Consider pharmacological treatment only when non-pharmacological measures fail to adequately control symptoms, as recommended by Praxis Medical Insights 1
First-line medications include midodrine, an alpha-1 agonist, with an initial dose of 2.5-5mg three times daily, which can increase standing systolic BP by 15-30 mmHg for 2-3 hours, as suggested by Praxis Medical Insights 1
Fludrocortisone, a mineralocorticoid, is also a first-line medication, with an initial dose of 0.05-0.1mg daily, which works by increasing plasma volume, as recommended by Praxis Medical Insights 1
Droxidopa is particularly effective for neurogenic orthostatic hypotension, as suggested by Praxis Medical Insights 1

The therapeutic goal should be minimizing postural symptoms rather than restoring normotension, as recommended by Praxis Medical Insights 1
Regular monitoring for adverse effects is essential, especially supine hypertension with pressor agents and electrolyte abnormalities with fludrocortisone, as advised by Praxis Medical Insights 1
For patients who do not respond to monotherapy, consider combination therapy with midodrine and fludrocortisone, as suggested by Praxis Medical Insights 1