From the Guidelines
Orthostatic hypotension is diagnosed when there is a sustained reduction in systolic blood pressure of at least 20 mmHg or diastolic blood pressure of at least 10 mmHg within three minutes of standing up from a sitting or lying position, as defined by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
Diagnostic Criteria
The diagnostic criteria for orthostatic hypotension include:
- A drop in systolic blood pressure of ≥20 mmHg or diastolic blood pressure of ≥10 mmHg within 1 and/or 3 min after standing following a 5-min period in the seated or lying position 1
- Blood pressure and heart rate measurements should be taken after the patient has been supine for at least 5 minutes, then immediately upon standing, and again at 1 minute and 3 minutes after standing
Causes and Symptoms
Orthostatic hypotension occurs due to inadequate compensatory mechanisms in the autonomic nervous system that normally increase vascular tone and heart rate to maintain blood pressure when changing positions. Common causes include:
- Dehydration
- Medication side effects (particularly from antihypertensives, antidepressants, and antipsychotics)
- Autonomic neuropathy
- Aging Symptoms of orthostatic hypotension may include:
- Lightheadedness
- Dizziness
- Blurred vision
- Weakness
- Fatigue
- Cognitive impairment
- Nausea
- Syncope
Assessment and Diagnosis
The diagnosis of orthostatic hypotension requires documentation of the blood pressure drop within the specified timeframe. Routine ABPM is not currently suitable for formally assessing orthostatic hypotension, though it may help in some cases, particularly when accompanied by a patient symptom diary 1.
From the Research
Diagnostic Criteria for Orthostatic Hypotension
The diagnostic criteria for orthostatic hypotension are as follows:
- A decrease in systolic blood pressure of 20 mm Hg or more within three minutes of standing from the supine position or on assuming a head-up position of at least 60 degrees during tilt table testing 2, 3, 4, 5, 6
- A decrease in diastolic blood pressure of 10 mm Hg or more within three minutes of standing from the supine position or on assuming a head-up position of at least 60 degrees during tilt table testing 2, 3, 4, 5, 6
Methods of Diagnosis
Diagnosis of orthostatic hypotension can be confirmed by:
- Performing a bedside simplified Schellong test, which consists of blood pressure and heart rate measurements after five minutes in the supine position and three minutes after moving to a standing position 2
- Head-up tilt table testing, which is recommended if the patient is unable to stand safely or if the clinical suspicion for orthostatic hypotension is high despite normal findings on the bedside test 2, 4
Classification of Orthostatic Hypotension
Orthostatic hypotension can be classified as:
- Neurogenic or nonneurogenic, depending on etiology and heart rate response 2