How do you obtain orthostatic blood pressure?

From the Guidelines

To obtain orthostatic blood pressure, measure the patient's blood pressure and heart rate after having them sit or lie for 5 minutes, and then 1 and/or 3 minutes after standing, with a threshold for orthostatic hypotension of ≥20/10 mmHg drop in systolic and diastolic blood pressure, respectively. This procedure is recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.

Key Steps to Obtain Orthostatic Blood Pressure:

• Have the patient sit or lie down for 5 minutes to ensure a stable baseline reading.
• Measure the patient's blood pressure and heart rate after the 5-minute rest period.
• Then, have the patient stand up and measure their blood pressure and heart rate 1 and/or 3 minutes after standing.
• Use a properly calibrated blood pressure cuff of appropriate size for the patient's arm circumference, as emphasized in the guidelines for office blood pressure measurement 1.
• The definition of orthostatic hypotension is a drop in systolic blood pressure of at least 20 mmHg or a drop in diastolic blood pressure of at least 10 mmHg within 1 and/or 3 minutes of standing, as defined in the 2024 ESC guidelines 1.

Importance of Orthostatic Blood Pressure Measurement:

Orthostatic hypotension can indicate volume depletion, autonomic dysfunction, or medication side effects, and its identification is crucial for patient management, especially in elderly or frail patients who may be at higher risk of falls and other complications 1. The measurement of orthostatic blood pressure is a simple yet valuable tool in clinical practice, providing insights into the patient's cardiovascular and autonomic nervous system function.

Clinical Considerations:

Patients may experience dizziness, lightheadedness, or syncope during position changes, so it is essential to ensure safety measures are in place to prevent falls, especially in vulnerable populations. The guidelines also recommend assessing for orthostatic hypotension at the initial visit and thereafter by symptoms, and considering non-pharmacological approaches as the first-line treatment for orthostatic hypotension among persons with supine hypertension 1.

From the Research

Obtaining Orthostatic Blood Pressure

To obtain orthostatic blood pressure, the following steps can be taken:

• Measure blood pressure in the supine and standing positions 2, 3
• Alternatively, measure seated and standing blood pressure, but note that this may produce smaller depressor responses due to reduced gravitational stress 2
• Heart rate responses to standing should be concomitantly measured to assess integrity of baroreflex function 2
• Use 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

Considerations for Measurement

When measuring orthostatic blood pressure, consider the following:

• Arm position can have a significant impact on determination of postural changes in blood pressure 4
• The combination of the arm parallel when supine and perpendicular when standing may significantly overestimate the orthostatic change 4
• Arm position should be held constant in supine and standing positions when assessing for orthostatic change in blood pressure 4

Diagnostic Criteria

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 2, 3