From the Guidelines
Orthostatic hypotension is diagnosed when there is a sustained reduction in systolic blood pressure of at least 20 mmHg or diastolic blood pressure of at least 10 mmHg within three minutes of standing up from a lying or sitting position, as defined by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. To determine positive orthostatic hypotension, the following criteria should be met:
- The patient should be seated or lying down for at least 5 minutes before the initial blood pressure measurement.
- Blood pressure should be measured at 1 and/or 3 minutes after standing.
- A drop of ≥20/10 mmHg in blood pressure is required for diagnosis. Some key points to consider:
- Symptoms such as lightheadedness, dizziness, blurred vision, weakness, fatigue, cognitive impairment, nausea, or syncope may accompany the blood pressure drop, but they are not required for diagnosis.
- The physiological basis for orthostatic hypotension is inadequate compensatory cardiovascular mechanisms that normally maintain blood pressure when changing positions.
- Common causes include dehydration, medication effects (particularly antihypertensives, antidepressants, and antipsychotics), autonomic neuropathy, and aging. It is essential to note that the diagnosis of orthostatic hypotension requires blood pressure measurements in both positions, typically using a manual or automated blood pressure cuff, as stated in the 2024 ESC guidelines 1. Additionally, the 2018 ESC guidelines for the diagnosis and management of syncope provide further insight into the diagnosis and classification of orthostatic hypotension, including the definition of classical orthostatic hypotension as a sustained decrease in systolic BP >_20 mmHg, diastolic BP >_10 mmHg, or a sustained decrease in systolic BP to an absolute value <90 mmHg within 3 min of active standing or head-up tilt of at least 60 degrees 1. However, the most recent and highest-quality study, the 2024 ESC guidelines, should be prioritized when making a definitive recommendation 1.
From the Research
Diagnosis of Orthostatic Hypotension
To determine positive orthostatic hypotension, the following criteria are used:
- A decrease in systolic blood pressure of 20 mm Hg or more within three minutes of standing when compared with blood pressure from the sitting or supine position 2, 3, 4, 5.
- A decrease in diastolic blood pressure of 10 mm Hg or more within three minutes of standing when compared with blood pressure from the sitting or supine position 2, 3, 4, 5.
Key Considerations
When evaluating suspected orthostatic hypotension, it is essential to:
- Identify reversible causes and underlying associated medical conditions 2, 3, 5.
- Consider head-up tilt-table testing to confirm a diagnosis of suspected orthostatic hypotension when standard orthostatic vital signs are nondiagnostic 2.
- Assess treatment response in patients with an autonomic disorder 2.
Symptoms and Causes
Orthostatic hypotension may be symptomatic or asymptomatic, with common symptoms including: