What is the definition and management of orthostatic hypotension?

From the Guidelines

Orthostatic hypotension is defined as a decrease of at least 20 mmHg in systolic blood pressure or 10 mmHg in diastolic blood pressure within three minutes of standing, as stated in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The management of orthostatic hypotension begins with non-pharmacological approaches, including:

• Gradual position changes
• Adequate hydration (2-3 liters of fluid daily)
• Increased salt intake (8-10g daily if not contraindicated)
• Compression stockings
• Avoiding triggers like hot environments, large meals, and alcohol Medications that may cause or worsen orthostatic hypotension should be reviewed and potentially adjusted. If these measures are insufficient, pharmacological treatment may include:
• Fludrocortisone (starting at 0.1mg daily, maximum 0.3mg daily) which increases sodium retention and blood volume
• Midodrine (2.5-10mg three times daily, with the last dose before 6pm) which constricts blood vessels
• Droxidopa (100-600mg three times daily) which raises blood pressure These medications work by either expanding blood volume or increasing vascular tone to maintain blood pressure upon standing, as recommended in the guidelines for the diagnosis and management of syncope (version 2009) 1. Patients should monitor their blood pressure in different positions and be aware that treatment aims to reduce symptoms rather than normalize all blood pressure readings, as overly aggressive treatment can lead to supine hypertension, as noted in the recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the subcommittee of professional and public education of the american heart association council on high blood pressure research 1. Education regarding the nature of the condition in conjunction with lifestyle advice can improve orthostatic symptoms markedly, even though the rise in BP is relatively small (10–15 mmHg); raising the standing BP just enough to be within the autoregulatory zone can make a substantial functional difference, as stated in the guidelines for the diagnosis and management of syncope (version 2009) 1.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations

Definition of Orthostatic Hypotension: The FDA drug label does not provide a direct definition of orthostatic hypotension. Management of Orthostatic Hypotension: The management includes non-pharmacologic treatment, such as:

• Support stockings
• Fluid expansion
• Lifestyle alterations Midodrine hydrochloride tablets can be used in patients whose lives are considerably impaired despite standard clinical care. The patient should be cautioned to report symptoms of supine hypertension immediately 2.

From the Research

Definition of Orthostatic Hypotension

• Orthostatic hypotension is defined as a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the supine position or on assuming a head-up position of at least 60 degrees during tilt table testing 3, 4, 5.
• This condition is characterized by symptoms such as headache, lightheadedness, shoulder and neck pain, visual disturbances, dyspnea, and chest pain, which are due to inadequate physiologic compensation and organ hypoperfusion 3.

Diagnosis of Orthostatic Hypotension

• Diagnosis is confirmed by performing a bedside simplified Schellong test, which consists of blood pressure and heart rate measurements after five minutes in the supine position and three minutes after moving to a standing position 3.
• If the patient is unable to stand safely or the clinical suspicion for orthostatic hypotension is high despite normal findings on the bedside test, head-up tilt table testing is recommended 3.

Management of Orthostatic Hypotension

• Treatment goals for orthostatic hypotension are reducing symptoms and improving quality of life 3, 6.
• Initial treatment focuses on the underlying cause and adjusting potentially causative medications 3, 7.
• Nonpharmacologic strategies include dietary modifications, compression garments, physical maneuvers, and avoiding environments that exacerbate symptoms 3, 7, 6.
• First-line medications include midodrine and droxidopa 3, 7, 6.
• Pharmacologic options also include volume expansion with fludrocortisone and sympathetic enhancement with norepinephrine reuptake inhibitors 6.

Classification of Orthostatic Hypotension

• Orthostatic hypotension is classified as neurogenic or nonneurogenic, depending on etiology and heart rate response 3, 4.
• Neurogenic orthostatic hypotension is characterized by autonomic failure due to central or peripheral nervous system disorders, while nonneurogenic orthostatic hypotension is mainly favored by hypovolemia 4.