What are the management strategies for hypotension and hypertension in an outpatient (OPD) setting?

Outpatient Management of Blood Pressure: Hypotension and Hypertension

Hypertension Management in OPD

For outpatient hypertension management, initiate pharmacological treatment when BP is ≥140/90 mmHg (or ≥130/80 mmHg in high-risk patients), targeting <130/80 mmHg for most adults using first-line agents (ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics) with monthly follow-up until target is achieved. 1

Initial Assessment and BP Goals

• Confirm elevated BP with proper measurement technique including repeated measurements in both arms 1
• Target BP <130/80 mmHg for most adults, though slightly higher targets (up to 140/90 mmHg) may be considered in older adults 2, 1
• Initiate pharmacological treatment when confirmed office BP ≥140/90 mmHg, or ≥130/80 mmHg if 10-year CVD risk ≥10% or high-risk conditions exist 2, 1

Lifestyle Modifications (First-Line for All Patients)

• DASH diet emphasizing fruits, vegetables, whole grains, and low-fat dairy (expected 3-5 mmHg SBP reduction) 1
• Sodium restriction to <1500 mg/day (1-3 mmHg reduction per 1000 mg sodium reduction) 1
• Weight loss targeting ideal body weight (1 mmHg reduction per 1 kg lost) 1
• Physical activity of 150 minutes/week moderate aerobic exercise 1
• Alcohol moderation to ≤2 drinks/day for men, ≤1 drink/day for women 1

Pharmacological Management

• First-line agents with proven mortality benefits: ACE inhibitors (e.g., lisinopril), ARBs, calcium channel blockers (e.g., amlodipine), and thiazide diuretics 1, 3, 4
• Stage 1 hypertension (140-159/90-99 mmHg): Start monotherapy with any first-line agent 1
• Stage 2 hypertension (≥160/100 mmHg): Start combination therapy with two first-line agents 1
• Preferred formulations: Long-acting agents (amlodipine, chlorthalidone) in fixed-dose combinations to improve adherence 1

Special Populations

• Diabetes or CKD: Target <130/80 mmHg; prefer ACE inhibitors or ARBs 1
• Older adults (≥85 years): Follow same guidelines as younger patients if well-tolerated; consider long-acting dihydropyridine CCBs or RAS inhibitors, avoid beta-blockers unless compelling indication 2
• Frail patients: Screen for frailty using validated tests; individualize targets considering health priorities and shared decision-making 2

Follow-Up Strategy

• Monthly visits until BP target achieved 1
• Home BP monitoring for medication titration and maintenance 1
• Screen for medication non-adherence, therapeutic inertia, and social determinants of health 1

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Hypotension Management in OPD

For outpatient orthostatic hypotension, prioritize non-pharmacological interventions including increased dietary salt (6-10 g/day), adequate hydration, compression therapy targeting the abdomen, and avoidance of prolonged supine positioning, while carefully reviewing and potentially discontinuing BP-lowering medications that worsen orthostatic symptoms. 2, 5

Initial Assessment

• Screen for orthostatic hypotension before starting or intensifying BP-lowering medications by measuring BP after 5 minutes sitting/lying, then at 1 and/or 3 minutes after standing 2
• Diagnostic criteria: Drop in SBP >20 mmHg or DBP >10 mmHg upon standing 2
• Distinguish neurogenic (associated with Parkinson's, synucleinopathies) from non-neurogenic causes as management differs 6
• Evaluate for symptomatic hypotension: dizziness, syncope, headache, visual disturbances, fatigue (symptoms matter more than absolute BP threshold) 2

Non-Pharmacological Management (First-Line)

• Increased dietary salt to 6-10 g/day to expand plasma volume 5
• Adequate hydration with 2-2.5 liters fluid daily 5
• Compression therapy: Full-length compression (lower limbs AND abdomen) or abdominal compression alone are superior to knee-length or thigh-length compression 7
• Avoid prolonged supine positioning: Supine posture triggers pressure natriuresis and extensive sodium loss in patients with supine hypertension 5
• Physical counterpressure maneuvers: Leg crossing, squatting, muscle tensing when symptoms occur 6
• Elevate head of bed 10-20 degrees to reduce nocturnal pressure natriuresis 6

Medication Review

• Deprescribe or switch BP-lowering medications that worsen orthostatic hypotension rather than simply de-intensifying therapy 2
• Discontinue or reduce other medications that lower BP: sedatives, prostate-specific alpha-blockers 2
• Caution with fludrocortisone: Effects are transient; contraindicated in heart failure; use cautiously if supine hypertension present 5

Special Consideration: Coexisting Hypertension and Orthostatic Hypotension

• Calcium channel blockers (particularly verapamil) may be beneficial as they can lower supine BP without worsening orthostatic hypotension and may improve baroreflex sensitivity 8
• Avoid medications that exacerbate orthostatic symptoms (alpha-blockers, non-selective beta-blockers) 2
• Focus on treating supine hypertension while managing orthostatic symptoms with non-pharmacological measures 9

Follow-Up

• Regular monitoring of both supine and standing BP 2
• Assess for falls, cognitive slowing, and functional impairment 6
• In neurogenic orthostatic hypotension, monitor for progression of underlying synucleinopathy 6

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Critical Pitfalls to Avoid

For Hypertension

• Therapeutic inertia: Failure to intensify treatment when BP remains above target 1
• Rapid BP reduction: Avoid lowering BP >25% within 6 hours in non-emergency settings (increases adverse event risk) 10
• White coat and masked hypertension: Use out-of-office BP monitoring for detection 1
• Polypharmacy without fixed-dose combinations: Reduces adherence 1

For Hypotension

• Treating orthostatic hypotension with IV fluids alone: Only ~54% respond to fluid bolus; consider vascular tone or inotropy issues 2
• Using knee-length or thigh-length compression: Inferior to abdominal or full-length compression 7
• Continuing all BP-lowering medications: Review and deprescribe rather than accepting symptomatic hypotension 2
• Ignoring supine hypertension: Triggers nocturnal pressure natriuresis and worsens orthostatic hypotension 5