How is orthostatic hypertension managed?

Management of Orthostatic Hypotension

The management of orthostatic hypotension should prioritize non-pharmacological approaches first, followed by careful medication selection that minimizes orthostatic effects, with long-acting dihydropyridine calcium channel blockers (CCBs) and renin-angiotensin system (RAS) inhibitors as preferred agents. 1

Diagnosis and Assessment

• Orthostatic hypotension is defined as a reduction in systolic blood pressure ≥20 mmHg or diastolic blood pressure ≥10 mmHg within 3 minutes of standing from a supine position 1
• Measurement protocol:
  • Measure BP after 5 minutes of rest in supine/sitting position
  • Repeat measurements at 1 minute and 3 minutes after standing
  • Use validated and calibrated BP measurement device 1
• Always test for orthostatic hypotension before starting or intensifying BP-lowering medication 1

Non-Pharmacological Management (First-Line)

1. Physical counter-pressure maneuvers:

   • Leg crossing, lower body muscle tensing, handgrip, and squatting 1
   • Effective for patients with sufficient prodrome and physical capability

2. Compression garments:

   • At least thigh-high and preferably including the abdomen 1
   • Help improve orthostatic symptoms and blunt BP decreases

3. Dietary modifications:

   • Acute water ingestion (≥240 mL) 30 minutes before standing 1
   • Increased salt intake (6-9g daily) unless contraindicated 1
   • Small, frequent meals to reduce postprandial hypotension 1

4. Sleep position adjustment:

   • Elevate head of bed by 10° to prevent nocturnal polyuria and ameliorate nocturnal hypertension 1

Pharmacological Management

For Hypertension with Orthostatic Hypotension

1. Preferred first-line agents 1:

   • Long-acting dihydropyridine calcium channel blockers
   • Renin-angiotensin system (RAS) inhibitors

2. Agents to avoid or use with caution 1:

   • Beta-blockers
   • Alpha-blockers
   • Diuretics

3. Special considerations for elderly/frail patients:

   • In patients ≥85 years or with moderate-to-severe frailty, use long-acting dihydropyridine CCBs or RAS inhibitors as first-line agents 1
   • Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension 2

For Symptomatic Orthostatic Hypotension

1. First-line medication:

   • Midodrine 5-20 mg three times daily (with last dose before 6 PM) 1

2. Alternative medication:

   • Fludrocortisone 0.1-0.3 mg daily 1, 3
   • Standard dosage for Addison's disease is 0.1 mg daily, although dosage ranging from 0.1 mg three times a week to 0.2 mg daily has been employed 3
   • If transient hypertension develops, reduce dose to 0.05 mg daily 3

Treatment Goals and Monitoring

• Aim to improve symptoms and functional status, not to target arbitrary BP values 4
• For patients with uncontrolled hypertension and orthostatic hypotension, switch BP-lowering medications that worsen orthostatic hypotension rather than simply reducing doses 1
• If target systolic BP of 120-129 mmHg is not tolerable, aim for "as low as reasonably achievable" (ALARA) systolic BP 1
• Monitor for supine hypertension, especially when using pressor medications 1
• Consider ambulatory BP monitoring to identify abnormal diurnal patterns 1

Special Populations

Diabetic Patients with Hypertension

• Orthostatic BP measurement should be performed to assess for autonomic neuropathy 2
• If ACE inhibitors or ARBs are used, monitor renal function and serum potassium levels 2

Elderly Patients

• BP-lowering treatment should be maintained lifelong if well tolerated, even beyond age 85 2, 1
• Consider BP-lowering treatment from ≥140/90 mmHg in patients with pre-treatment symptomatic orthostatic hypotension 2
• Review medications that may cause or worsen orthostatic hypotension 1

Complications and Pitfalls

• Supine hypertension is a common complication of treatment for orthostatic hypotension 1, 5
• Aggressive treatment of orthostatic intolerance can worsen supine hypertension 5
• Fludrocortisone, while effective for symptom improvement, has concerning long-term effects including renal and cardiac failure and increased risk of all-cause hospitalization 6, 7
• Avoiding bedrest deconditioning is crucial in reducing hospital stay for patients with orthostatic hypotension 8

Remember that the treatment goal in orthostatic hypotension should be to improve symptoms and functional status, not to achieve perfect blood pressure control 4, 5.