What is the treatment for hypotension?

Treatment of Hypotension

The treatment of hypotension should be guided by its underlying cause, with immediate intervention using vasopressors like norepinephrine for severe cases, while orthostatic hypotension requires a stepwise approach starting with non-pharmacological measures before advancing to medications like midodrine or fludrocortisone. 1, 2, 3

Diagnosis and Classification of Hypotension

Hypotension can be categorized based on clinical presentation:

• Acute hypotension: Systolic BP <90 mmHg with signs of shock or organ hypoperfusion
• Chronic hypotension: Persistently low BP without acute symptoms
• Orthostatic hypotension: ≥20 mmHg drop in systolic or ≥10 mmHg drop in diastolic BP within 3 minutes of standing 2

Key diagnostic steps:

• Measure BP in both supine and standing positions
• Assess for symptoms: dizziness, lightheadedness, syncope, fatigue, visual disturbances
• Evaluate volume status and cardiac function
• Review medication list for potential causes

Treatment Algorithm for Hypotension

1. Acute Severe Hypotension/Shock

For patients with signs of shock or severe hypotension (SBP <90 mmHg with organ hypoperfusion):

1. Assess fluid responsiveness:

   • Perform passive leg raise test to predict fluid responsiveness 1
   • If positive response to passive leg raise, administer IV fluids

2. If fluid unresponsive or requiring immediate pressure support:

   • Norepinephrine is the first-line vasopressor (starting at 0.2-1.0 μg/kg/min) 1, 3
   • Add dobutamine (2-20 μg/kg/min) if cardiac dysfunction is present 1
   • For bradycardia with hypotension, consider dopamine (3-5 μg/kg/min) 1

3. Monitor response:

   • Target MAP ≥65 mmHg or individualized goal based on patient's baseline 1
   • Assess tissue perfusion markers (lactate clearance, urine output)

2. Orthostatic Hypotension

For patients with orthostatic hypotension:

1. First-line: Non-pharmacological measures 2

   • Increase fluid intake to 2-3 liters daily
   • Increase salt intake to 6-9g daily
   • Compression garments (thigh-high stockings with 30-40 mmHg pressure)
   • Physical counterpressure maneuvers (leg crossing, squatting)
   • Elevate head of bed 10° when sleeping
   • Small, frequent meals with reduced simple carbohydrates

2. Second-line: Pharmacological therapy 2, 4

   • Fludrocortisone 0.1mg daily for volume expansion
   • Midodrine 5-20mg three times daily (avoid within 4 hours of bedtime)
   • Droxidopa 100-600mg three times daily for neurogenic orthostatic hypotension
   • Pyridostigmine 30mg 2-3 times daily for refractory cases

3. Chronic Asymptomatic Hypotension

For patients with chronic, asymptomatic hypotension:

• No treatment is typically required if asymptomatic 5
• Monitor for development of symptoms
• Avoid medications that may worsen hypotension

Special Considerations

Hypotension in Heart Failure

For heart failure patients with hypotension during medication titration 1, 6:

1. First reduce non-heart failure medications that lower BP
2. Decrease diuretic dose if no congestion is present
3. Consider temporary dose reduction of heart failure medications
4. Do not completely discontinue disease-modifying therapies if possible

Postoperative Hypotension

For postoperative patients with hypotension 1:

• Assess fluid responsiveness with passive leg raise test
• If fluid responsive, administer IV fluids
• If not fluid responsive, consider vasopressors based on hemodynamic profile

Medication-Induced Hypotension

• Identify and discontinue or adjust doses of offending medications
• Common culprits: antihypertensives, diuretics, antidepressants, antipsychotics, antiparkinsonian medications, and opioids 2

Monitoring and Follow-up

• Regular BP monitoring in both supine and standing positions
• Assess symptom improvement using symptom diaries
• Monitor for supine hypertension, especially with pharmacological therapy
• For patients on fludrocortisone, monitor electrolytes and weight 2

Common Pitfalls to Avoid

• Treating asymptomatic chronic hypotension unnecessarily 5
• Failing to identify and address underlying causes
• Overlooking orthostatic hypotension as a cause of falls in elderly patients 2
• Focusing solely on BP numbers rather than symptom improvement
• Inadequate monitoring for supine hypertension with pharmacological therapy
• Administering vasopressors too close to bedtime in orthostatic hypotension

By following this structured approach to hypotension management, clinicians can effectively address this common cardiovascular disorder while minimizing complications and improving patient outcomes.