What are the conservative management strategies for postural hypotension?

From the Guidelines

Conservative management of postural hypotension should prioritize non-pharmacological approaches, including lifestyle modifications, physical countermeasures, and compression garments, as these can significantly improve symptoms and quality of life without the risks associated with medication. The most effective conservative management strategies for postural hypotension include:

• Lifestyle modifications such as rising slowly from sitting or lying positions, avoiding prolonged standing, and staying well-hydrated by drinking 2-3 liters of fluid daily 1
• Increasing salt intake to 6-10 grams per day to help maintain blood volume, unless contraindicated by heart failure or kidney disease 1
• Compression garments like waist-high stockings (30-40 mmHg compression) to improve venous return 1
• Physical countermaneuvers such as crossing legs while standing, squatting, or tensing lower body muscles to temporarily raise blood pressure when symptoms occur 1
• Avoiding triggers like hot environments, large meals, and alcohol consumption 1
• Elevating the head of the bed by 4-6 inches to reduce nocturnal diuresis and morning hypotension by decreasing supine hypertension 1
• Small, frequent meals to minimize postprandial hypotension 1 These non-pharmacological approaches work by improving venous return, maintaining blood volume, and reducing venous pooling, which collectively help maintain cerebral perfusion when changing positions, as supported by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1. It is essential to try these conservative management strategies consistently for several weeks before considering medication options, as they can significantly improve symptoms and quality of life without the risks associated with medication, as recommended by the European Heart Journal guidelines for the diagnosis and management of syncope 1 and the Diabetes Care standards of medical care in diabetes-2021 1.

From the Research

Conservative Management Strategies

Conservative management strategies for postural hypotension include nonpharmacologic measures such as:

• Increasing fluid and salt intake 2
• Performing physical maneuvers like leg-crossing, bending forward, and placing a foot on a chair to increase thoracic blood volume 3
• Sleeping with the head of bed elevated 4
• Exercising regularly 4
• Avoiding known stressors 4
• Managing underlying related conditions such as diabetes mellitus 4

Pharmacologic Interventions

If nonpharmacologic measures prove insufficient, pharmacologic interventions may be necessary. These include:

• Fludrocortisone, which increases blood volume and blood pressure 2, 5, 6
• Midodrine, which can help prevent orthostatic hypotension 2, 4
• Indomethacin, which can be used to treat postural hypotension 2
• Atrial tachypacing, which can be used to treat postural hypotension 2
• Pyridostigmine, which can help prevent orthostatic hypotension 4, 6
• Droxidopa, which can help prevent orthostatic hypotension 4

Individualized Treatment Approach

It is essential to understand the underlying suspected etiology of postural hypotension to select promising pharmacologic agents 4. An individualized treatment approach is necessary, as the etiology and severity of autonomic dysfunction vary widely between patients 4. The goal of treatment is to make the patient as ambulatory and symptom-free as possible without causing supine hypertension 2.