From the Guidelines
For an 87-year-old man with cardiac and renal issues presenting with orthostatic hypotension, I recommend a comprehensive evaluation including complete blood count, comprehensive metabolic panel, thyroid function tests, and cardiac biomarkers, as well as orthostatic vital signs and medication review, to identify the underlying cause of orthostatic hypotension and guide treatment. The patient's symptoms of dizziness with standing up out of bed and resolving in 2 minutes suggest orthostatic hypotension, which can be exacerbated by cardiac and renal issues. A complete blood count will assess for anemia, which can worsen orthostatic symptoms 1. The metabolic panel should include electrolytes, BUN, and creatinine to evaluate renal function and detect electrolyte imbalances that may contribute to hypotension. Given his cardiac history, an ECG, echocardiogram, and cardiac biomarkers like troponin and BNP are important to assess cardiac function and rule out acute cardiac events. Medication review is essential as many cardiac and blood pressure medications can cause or worsen orthostatic hypotension, and switching to alternative therapies may be necessary, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. Additional tests should include urinalysis to assess hydration status and renal function, and a morning cortisol level to rule out adrenal insufficiency. In patients with renal issues, careful attention to fluid status through physical examination and possibly chest X-ray may be warranted.
The patient's treatment should prioritize non-pharmacological approaches as the first-line treatment of orthostatic hypotension, including behavioral strategies such as gradual staged movements with postural change, mild isotonic exercise, head-up bed position during sleep, physical counter-manoeuvres, and increased fluid and salt intake if not contraindicated 1. If symptoms persist, pharmacological treatment with midodrine or 9-α-fluorohydrocortisone may be considered, with careful monitoring of potential adverse effects and supine hypertension. The goal of treatment should be to minimize postural symptoms rather than to restore normotension, and the potential risks of a drug should be weighed against its possible benefit.
Key tests and labs to order include:
- Complete blood count
- Comprehensive metabolic panel
- Thyroid function tests
- Cardiac biomarkers (troponin, BNP)
- ECG
- Echocardiogram
- Orthostatic vital signs
- Urinalysis
- Morning cortisol level
- Medication review
- Chest X-ray (if necessary to assess fluid status)
From the Research
Diagnostic Approach
To diagnose orthostatic hypotension in an 87-year-old man with cardiac and renal issues, the following steps can be taken:
- Perform 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 2
- 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 2
- Establish whether symptoms are due to orthostatic hypotension by careful history taking, a thorough physical examination, and supine and upright blood pressure measurements 3
Laboratory Tests
The following laboratory tests may be useful in evaluating the underlying cause of orthostatic hypotension:
- Blood tests to evaluate renal function, electrolyte levels, and blood glucose levels
- Electrocardiogram (ECG) to evaluate cardiac function
- Echocardiogram to evaluate cardiac structure and function
Classification and Treatment
Orthostatic hypotension can be classified as neurogenic or non-neurogenic, depending on the etiology and heart rate response 2, 3
- Treatment goals for orthostatic hypotension are reducing symptoms and improving quality of life
- Initial treatment focuses on the underlying cause and adjusting potentially causative medications
- Nonpharmacologic strategies include dietary modifications, compression garments, physical maneuvers, and avoiding environments that exacerbate symptoms 2, 3
- First-line medications include midodrine and droxidopa, although fludrocortisone may also be used in some cases 4, 2, 5