From the Guidelines
To properly take orthostatic vital signs, have the patient sit or lie for 5 minutes, then measure their blood pressure 1 and/or 3 minutes after standing, with a threshold for orthostatic hypotension of ≥20/10 mmHg (systolic BP/diastolic BP) drop. This is based on the most recent guidelines from the European Heart Journal, as stated in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
When performing the test, ensure the patient's safety by having them near the bed or with assistance available in case of dizziness. The test should be performed in a quiet, comfortable environment, and the patient should avoid caffeine, alcohol, and large meals beforehand.
- The patient should relax in a sitting or lying position for at least 5 minutes before the measurement.
- The patient should avoid caffeine, exercise, and smoking for at least 30 minutes before measurement.
- Ensure the patient has emptied their bladder before the measurement.
- Neither the patient nor the observer should talk during the rest period or during the measurement.
- Remove all clothing covering the location of cuff placement.
Orthostatic measurements help diagnose conditions like orthostatic hypotension, which occurs when the autonomic nervous system fails to adequately compensate for positional changes by constricting blood vessels and increasing heart rate to maintain blood pressure when standing. The 2024 ESC guidelines recommend testing for orthostatic hypotension before starting or intensifying BP-lowering medication 1.
It is also important to note that orthostatic hypotension is defined as a BP drop of ≥20/10 mmHg 1 and/or 3 min after standing following a 5-min period in the seated or lying position, as stated in the 2024 ESC guidelines 1.
In terms of prioritizing the patient's safety and well-being, it is crucial to consider the potential risks and consequences of orthostatic hypotension, particularly in older adults or those with underlying medical conditions. By following the recommended guidelines and taking necessary precautions, healthcare providers can help minimize these risks and ensure the best possible outcomes for their patients.
From the Research
Orthostatic Measurements
- Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mmHg or more and in diastolic blood pressure of 10 mmHg or more within 3 minutes of standing 2
- Blood pressure should be measured in the supine position and in the orthostatic position after 1 and 3 minutes 2
Factors Influencing Orthostatic Hypotension
- Age: Orthostatic hypotension is most common in the elderly 3, 4
- Medications: Certain medications such as diuretics, antidepressants, sympatholytics, and vasodilators can elicit orthostatic hypotension 3, 4
- Comorbidities: Conditions such as autonomic dysfunction, reduced circulating volume, and limited heart rate increase can contribute to orthostatic hypotension 3, 4
- Polypharmacy: The use of multiple medications can increase the risk of orthostatic hypotension 5
Preventing Orthostatic Hypotension
- Getting up slowly can help prevent orthostatic hypotension 3
- Medication adjustments may be necessary to prevent orthostatic hypotension 3, 4
- Reducing doses or prolonging dose intervals of certain medications can help avoid orthostatic hypotension in elderly patients 4
Special Considerations
- In older adults with dementia, orthostatic hypotension-related syncope is significantly related to treatment with certain medications such as nitrates, combinations of ACE-Is and diuretics, and combinations of ACE-Is and nitrates 2
- Alpha-blockers have been associated with orthostatic hypotension, particularly in patients with multimorbidity or polypharmacy 5