From the Research
Introduction to Orthostatic Hypotension
Orthostatic hypotension is a condition characterized by a significant decrease in blood pressure upon standing, which can lead to adverse outcomes even in asymptomatic individuals 1. The workup for orthostatic hypotension involves a comprehensive approach to identify the underlying cause and manage the condition effectively.
Clinical Presentation and Diagnosis
The clinical presentation of orthostatic hypotension can vary, ranging from cognitive slowing and unexplained falls to classic presyncope and syncope 1. Establishing whether symptoms are due to orthostatic hypotension requires careful history taking, a thorough physical examination, and supine and upright blood pressure measurements 1, 2. The diagnosis of orthostatic hypotension is based on a decrease in systolic blood pressure of at least 20 mm Hg or a decrease in diastolic blood pressure of at least 10 mm Hg within three minutes of standing 2, 3.
Causes of Orthostatic Hypotension
The causes of orthostatic hypotension can be categorized into neurogenic and non-neurogenic causes. Neurogenic causes include multisystem atrophy, diabetic neuropathy, and Parkinson's disease 1, 2. Non-neurogenic causes include dehydration, hypovolemia, cardiac insufficiency, and medication side effects 2, 4.
Evaluation and Management
The evaluation of suspected orthostatic hypotension begins by identifying reversible causes and underlying associated medical conditions 3. The management of orthostatic hypotension involves a stepwise, individualized, and primarily non-pharmacological approach 1. This may include:
- Cessation of blood pressure lowering drugs
- Adoption of lifestyle measures, such as counterpressure maneuvers
- Treatment with pharmacological agents, such as fludrocortisone, midodrine, and pyridostigmine, in selected cases 3
- Non-pharmacologic treatment, including avoidance of precipitating factors and physical and dietary interventions 5
Treatment Considerations
The treatment of orthostatic hypotension should aim to improve hypotension without excessive supine hypertension, relieve orthostatic symptoms, and improve standing time 3. The dosage and duration of treatment may vary depending on the underlying cause and the individual patient's response to treatment.
Differential Diagnosis and Caveats
The differential diagnosis of orthostatic hypotension includes other conditions that may cause similar symptoms, such as postural orthostatic tachycardia syndrome and vasovagal syncope 2. It is essential to consider these conditions when evaluating a patient with suspected orthostatic hypotension. Additionally, the management of orthostatic hypotension should be tailored to the individual patient's needs, taking into account the underlying cause and any comorbid conditions 1, 5.