From the Guidelines
Orthostatic hypotension is defined as a drop in systolic blood pressure of at least 20 mmHg or a drop in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing, as measured 1 and/or 3 minutes after standing following a 5-minute period in the seated or lying position. This definition is based on the most recent guidelines from the European Heart Journal, specifically the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
Key Points to Consider
- The patient should be assessed for orthostatic hypotension at the initial visit and if concerning symptoms arise, with measurement of blood pressure after 5 minutes of rest in the sitting or lying position, and then at 1 and/or 3 minutes after standing 1.
- The threshold for orthostatic hypotension is a drop of ≥20/10 mmHg (systolic BP/diastolic BP) 1.
- Measurement after lying may be more sensitive for detecting orthostatic hypotension and may better predict falls, but may be less feasible than measurement after sitting in clinical practice 1.
- Symptoms such as lightheadedness, dizziness, or syncope during the test strengthen the diagnosis of orthostatic hypotension.
Importance of Accurate Diagnosis
Accurate diagnosis of orthostatic hypotension is crucial for identifying patients at risk of falls and for guiding appropriate treatment, including non-pharmacological approaches and potential adjustments to blood pressure-lowering medications 1. The most recent and highest quality study, the 2024 ESC guidelines, provides the basis for the definition and diagnosis of orthostatic hypotension, prioritizing morbidity, mortality, and quality of life as the outcome 1.
From the Research
Definition of Orthostatic Hypotension
The criteria for orthostatic hypotension include:
- A decrease in systolic blood pressure of 20 mm Hg or more within three minutes of standing 2, 3, 4, 5, 6
- A decrease in diastolic blood pressure of 10 mm Hg or more within three minutes of standing 2, 3, 4, 5, 6
- These changes in blood pressure are compared to measurements taken from the sitting or supine position 2, 6
Diagnostic Methods
Diagnostic methods for orthostatic hypotension include:
- Active stand with continuous blood pressure monitoring, which is preferable to a tilt test for identifying initial orthostatic hypotension 4
- A 5-minute rest is required before measuring baseline blood pressure 4
- At least 2 minutes in the upright position is required for diagnosis 4
- Head-up tilt-table testing can aid in confirming a diagnosis of suspected orthostatic hypotension when standard orthostatic vital signs are nondiagnostic 2, 6
Measurement Devices
The use of continuous and interval blood pressure measurement devices for diagnosing orthostatic hypotension has been studied, with findings indicating that:
- Continuous blood pressure measurement devices may detect a higher prevalence of orthostatic hypotension compared to interval devices 5
- However, the concordance between interval and continuous measures is low, resulting in low positive and negative proportions of agreement in the diagnosis of orthostatic hypotension 5