Is it safe to discharge a patient with orthostatic (low blood pressure) hypotension?

Discharging Patients with Orthostatic Hypotension: Safety Considerations

Discharging a patient with orthostatic hypotension requires careful assessment and management of risk factors, as orthostatic hypotension is associated with increased risk of falls and adverse cardiovascular outcomes. 1

Assessment Before Discharge

Definition and Testing

• Orthostatic hypotension is defined as a decrease in systolic blood pressure of ≥20 mmHg or diastolic blood pressure of ≥10 mmHg within 3 minutes of standing 2, 3
• Test for orthostatic hypotension by:
  • Having patient rest in sitting or lying position for 5 minutes
  • Measure BP at 1 minute and/or 3 minutes after standing 2
  • Document both the BP changes and any associated symptoms

Risk Stratification

Patients at higher risk who may require additional interventions before discharge:

• Elderly patients (≥65 years) 3
• Diabetic patients with autonomic dysfunction 2
• Patients with cardiovascular disease 1
• Patients with significant BP drop (>30 mmHg systolic) 3
• Patients with symptomatic orthostatic hypotension 4
• Patients on multiple medications that can worsen orthostatic hypotension 1

Pre-Discharge Interventions

Medication Review

• Identify and adjust medications that worsen orthostatic hypotension:
  • Diuretics
  • Vasodilators
  • Antidepressants
  • Alpha-blockers 1

Patient Education

• Instruct patients on:
  • Gradual position changes (lying to sitting, sitting to standing)
  • Physical counter-maneuvers (leg crossing, muscle tensing)
  • Increasing fluid intake to 2-2.5 liters per day
  • Increasing salt intake to 6-10g/day (if not contraindicated)
  • Eating smaller, more frequent meals 1

Non-Pharmacological Interventions

• Recommend compression garments (thigh-high compression stockings)
• Advise on avoiding large carbohydrate-rich meals
• Suggest elevating the head of the bed by 10-15 cm during sleep 1

Pharmacological Management

For patients with persistent symptomatic orthostatic hypotension:

• Consider midodrine (starting dose 2.5-5 mg three times daily)
• Consider fludrocortisone (initial dose 0.05-0.1 mg daily) 1, 3

Discharge Safety Criteria

A patient with orthostatic hypotension can be safely discharged when:

1. The patient demonstrates ability to stand safely without severe symptoms
2. Orthostatic BP drop is less than 20 mmHg systolic or is asymptomatic
3. Patient understands warning signs requiring medical attention
4. Patient has demonstrated ability to perform physical counter-maneuvers
5. Medication adjustments have been made and patient has been observed for response
6. Home circumstances are adequate for managing the condition 4

Post-Discharge Follow-up

• Arrange follow-up within 1-2 weeks for patients with symptomatic orthostatic hypotension
• Provide home BP monitoring instructions if available
• Ensure patient has contact information for reporting worsening symptoms 1

Special Considerations

Patients with Diabetes

• Require closer monitoring due to higher risk of autonomic dysfunction
• May need more aggressive intervention before discharge 2

Patients with Heart Failure

• May require careful balance between heart failure medications and orthostatic hypotension management
• Consider starting heart failure medications at very low doses 1

Elderly Patients

• Higher fall risk necessitates more conservative BP goals
• May benefit from home health services after discharge 3

Pitfalls to Avoid

1. Discharging without adequate testing: Always perform orthostatic vital signs before discharge
2. Overlooking medication effects: Review all medications for potential orthostatic effects
3. Inadequate patient education: Ensure patients understand position change techniques
4. Failure to arrange follow-up: All patients with significant orthostatic hypotension need timely follow-up
5. Ignoring home circumstances: Assess home environment safety before discharge 4

Orthostatic hypotension is common in hospitalized patients (up to 60% in some settings) and often persists after discharge, creating ongoing risks of falls and cardiovascular complications 4. Therefore, careful assessment and management before discharge is essential to ensure patient safety.