How to manage a patient with hypotension?

Management of Hypotension

The management of hypotension requires identifying the underlying cause and implementing targeted interventions, with non-pharmacological approaches as first-line treatment followed by appropriate pharmacological therapy if needed. 1

Initial Assessment

• Test for orthostatic hypotension by having the patient sit or lie for 5 minutes and then measuring BP at 1 and/or 3 minutes after standing 1
• Document symptoms that correlate with hypotension: dizziness, lightheadedness, fatigue, visual disturbances
• Evaluate for potential causes:
  • Medication-related (diuretics, antihypertensives, alpha-blockers)
  • Volume depletion (dehydration, bleeding)
  • Autonomic dysfunction
  • Cardiac causes (arrhythmias, heart failure)
  • Endocrine disorders (adrenal insufficiency)

Management Algorithm

Step 1: Non-Pharmacological Interventions (First-Line)

• Correct transient causes:

  • Treat dehydration with fluid repletion
  • Address bleeding if present
  • Treat underlying infections

• Modify medication regimen:

  • Discontinue or reduce medications that worsen hypotension
  • Adjust timing of antihypertensive medications (avoid bedtime dosing)
  • Switch BP-lowering medications that worsen orthostatic hypotension to alternative therapy 1

• Lifestyle modifications:

  • Physical counter-pressure maneuvers (leg crossing, squatting, isometric exercises) 2
  • Compression garments for lower extremities
  • Increased salt and fluid intake (2-3L daily)
  • Small, frequent meals to reduce postprandial hypotension
  • Elevate head of bed by 6-9 inches (10-20°) during sleep 2

Step 2: Pharmacological Management (If Non-Pharmacological Measures Insufficient)

• For orthostatic hypotension:

  • Midodrine: 2.5-10 mg three times daily, with last dose at least 4 hours before bedtime 2, 3

    • Monitor for supine hypertension
    • Contraindicated in severe cardiac disease, acute kidney injury, urinary retention

  • Fludrocortisone: 0.1-0.3 mg daily 2

    • Use cautiously due to risk of worsening supine hypertension
    • Monitor for fluid retention, electrolyte imbalances

  • Droxidopa: For neurogenic orthostatic hypotension 2

• For persistent hypotension:

  • Ephedrine: 25-50 mg orally, 3-4 times daily 1

• For acute hypotension (in monitored settings):

  • Phenylephrine: 1-10 mcg/kg/min IV 1
  • Dopamine: 5-15 mcg/kg/min IV 1

Special Populations

Elderly and Frail Patients

• Start with lower doses of medications
• For patients aged ≥85 years or with moderate-to-severe frailty, consider long-acting dihydropyridine CCBs or RAS inhibitors as initial therapy 1
• Monitor closely for adverse effects
• Consider deprescribing BP-lowering medications if BP drops with progressing frailty 1

Patients with Comorbidities

• Diabetes: Target systolic BP to 120-129 mmHg if tolerated 1
• Chronic kidney disease: Target systolic BP to 120-129 mmHg if eGFR >30 mL/min/1.73m² 1
• Heart failure: Use medications with BP-lowering effects that improve outcomes (ACE inhibitors/ARBs, beta-blockers, MRAs, SGLT2 inhibitors) 1
• Supine hypertension with orthostatic hypotension: Use non-pharmacological approaches as first-line treatment 1

Monitoring and Follow-up

• Regular BP measurements in both supine and standing positions
• Assess for symptoms improvement
• Monitor for supine hypertension, especially with pressor medications
• Follow up every 3 months once stabilized

Important Pitfalls to Avoid

• Treating the BP number rather than the patient's symptoms and clinical status
• Aggressive BP lowering in elderly patients without considering frailty status
• Overlooking medications that can cause or worsen hypotension (including non-cardiovascular drugs)
• Failing to test for orthostatic hypotension before initiating or intensifying BP-lowering medication
• Using beta-blockers as first-line therapy in elderly patients with hypotension (unless specifically indicated)
• Administering pressor agents too close to bedtime, risking supine hypertension

Remember that the goal of treatment is to minimize symptoms and improve standing time for activities of daily living, not necessarily to normalize blood pressure numbers.