What is the management of positional (orthostatic) hypertension?

From the Guidelines

The management of positional (orthostatic) hypertension is not directly addressed in the provided evidence, which focuses on orthostatic hypotension, but based on the most recent and highest quality study, the approach to managing positional hypertension would likely involve minimizing postural symptoms and utilizing non-pharmacologic measures such as ensuring adequate salt intake, avoiding medications that aggravate hypertension, and using compressive garments over the legs and abdomen, as well as pharmacologic measures like shorter-acting antihypertensive drugs at bedtime 1.

Key Considerations

• The therapeutic goal in managing positional hypertension would be to minimize symptoms and prevent complications, rather than solely focusing on restoring normotension.
• Non-pharmacologic measures are crucial and include ensuring adequate salt intake, avoiding medications that could worsen hypertension, and the use of compressive garments.
• Pharmacologic management might involve shorter-acting antihypertensive medications administered at bedtime to manage supine hypertension, which is often higher in individuals with orthostatic intolerance, with options potentially including guanfacine, clonidine, shorter-acting calcium blockers like isradipine, or shorter-acting β-blockers such as atenolol or metoprolol tartrate, based on the treatment approach for orthostatic hypotension 1.
• It's essential to individualize treatment based on the patient's comorbidities, potential side effects of medications, and the specific characteristics of their positional hypertension.
• Monitoring blood pressure in different positions is vital to assess the efficacy of the treatment plan.

Pharmacological Management

• While the provided evidence does not directly address the pharmacological management of positional hypertension, the principles of using shorter-acting medications that can be administered at bedtime to manage supine blood pressure could be applied, considering the patient's overall clinical picture and potential for side effects.
• The choice of antihypertensive medication should be guided by the patient's comorbid conditions, the presence of other cardiovascular risk factors, and the specific features of their hypertension.

Lifestyle Modifications

• Lifestyle modifications play a critical role in the management of hypertension, including positional hypertension, and should be recommended as part of the overall treatment plan.
• These modifications include weight loss if the patient is overweight, sodium restriction, regular physical activity, and moderation of alcohol consumption.
• Patients should also be advised on how to change positions slowly to minimize symptoms associated with positional changes.

From the FDA Drug Label

The potential for supine and sitting hypertension should be evaluated at the beginning of midodrine therapy. Midodrine should be used with caution in orthostatic hypotensive patients who are also diabetic, as well as those with a history of visual problems who are also taking fludrocortisone acetate, which is known to cause an increase in intraocular pressure and glaucoma.

The management of positional (orthostatic) hypertension is not directly addressed in the provided drug label.

• Key points to consider in managing hypertension with midodrine include:
  • Evaluating the potential for supine and sitting hypertension at the beginning of therapy
  • Using midodrine with caution in patients with certain comorbidities, such as diabetes or visual problems
  • Avoiding concomitant use of drugs that increase blood pressure 2

From the Research

Definition and Pathophysiology of Positional Hypertension

• Positional hypertension, also known as orthostatic hypertension, refers to a sustained increase in blood pressure after standing 3.
• The primary pathophysiological disturbance in orthostatic hypertension is considered to be dysfunction of the autonomous nervous system, similar to orthostatic hypotension 3.
• Orthostatic hypertension has been related to subclinical or clinical target organ damage in some studies, but the association is not consistent across all studies 3.

Diagnosis and Clinical Implications

• The definition of orthostatic hypertension varies across different studies, making it challenging to compare relevant outcomes 3.
• Orthostatic hypertension is often underappreciated in clinical practice, possibly due to its unfamiliarity to many clinicians 4.
• A diagnostic and management approach to orthostatic hypertension involves identifying the underlying cause, such as autonomic dysfunction or vascular adrenergic hypersensitivity 4.

Management and Treatment

• There is limited evidence on the treatment of orthostatic hypertension, and no specific recommendations have been developed 3.
• The management of orthostatic hypertension may involve addressing the underlying cause, such as controlling diabetes mellitus or treating autonomic dysfunction 4.
• In contrast, orthostatic hypotension can be managed with medications such as fludrocortisone, midodrine, or other agents, but the evidence for these treatments is mostly based on studies of orthostatic hypotension rather than orthostatic hypertension 5, 6.

Prognostic Role and Clinical Significance

• Orthostatic hypertension appears to predict the risk for progression to arterial hypertension in younger individuals and the risk of cardiovascular morbidity and mortality in older persons 7.
• The presence of orthostatic hypertension may affect clinical management decisions, such as the choice of antihypertensive drugs, but more research is needed to determine the best approach 7.