What to do for hypotension?

Management of Blood Pressure 104/56

A blood pressure of 104/56 mmHg requires assessment for symptoms and orthostatic changes before any intervention, as this reading alone does not automatically warrant treatment. 1

Initial Assessment

Measure orthostatic vital signs immediately by checking blood pressure after 5 minutes of lying/sitting, then at 1 and 3 minutes after standing to determine if orthostatic hypotension is present (defined as a drop ≥20 mmHg systolic or ≥10 mmHg diastolic). 1, 2

Key Questions to Address:

• Is the patient symptomatic? Look for dizziness, lightheadedness, blurred vision, weakness, fatigue, syncope, or falls. 3, 4
• Is this a new finding or chronic? Acute hypotension requires more urgent evaluation. 5
• What medications is the patient taking? Drug-induced hypotension is the most common reversible cause, particularly from diuretics, vasodilators, antihypertensives, and psychotropic medications. 2
• Are there signs of volume depletion? Check for dehydration, blood loss, or reduced oral intake. 1, 4

Management Based on Clinical Scenario

If Asymptomatic with No Orthostatic Changes:

No treatment is necessary. 1 This blood pressure may represent the patient's baseline, particularly in younger individuals or those with good cardiovascular fitness. Simply document the finding and reassess if symptoms develop. 4

If Symptomatic or Orthostatic Hypotension Present:

Step 1: Address Reversible Causes

• Discontinue or reduce offending medications rather than simply lowering doses—switch to alternative agents if blood pressure control is needed. 2 Common culprits include ACE inhibitors, calcium channel blockers, alpha-blockers, and diuretics. 2
• Correct volume depletion with fluid resuscitation using normal saline or balanced crystalloids in 10-20 mL/kg boluses if hypovolemia is suspected. 1
• Avoid alcohol, which causes orthostatic intolerance through central nervous system effects and volume depletion. 2

Step 2: Non-Pharmacological Interventions (First-Line for All Patients)

• Increase fluid intake to 2-3 liters daily and salt consumption to 6-9 grams daily, unless contraindicated by heart failure. 1, 2
• Teach physical counter-maneuvers: leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes—particularly effective in patients under 60 years. 1, 2
• Use compression garments: waist-high stockings (30-40 mmHg) and abdominal binders to reduce venous pooling. 1, 2
• Elevate the head of bed by 10 degrees during sleep to prevent nocturnal polyuria and supine hypertension. 1, 2
• Recommend smaller, more frequent meals to reduce post-prandial hypotension. 1, 2
• Encourage regular physical activity to prevent deconditioning, which worsens orthostatic intolerance. 2
• Acute water ingestion of ≥480 mL can provide temporary relief with peak effect at 30 minutes. 1, 2

Step 3: Pharmacological Treatment (If Non-Pharmacological Measures Fail)

The therapeutic goal is minimizing postural symptoms and improving functional capacity, not restoring normotension. 1, 2

First-line medication: Midodrine 1, 2, 6

• Start at 2.5-5 mg three times daily 2, 6
• Take last dose at least 3-4 hours before bedtime to prevent supine hypertension 2, 6
• Increases standing systolic BP by 15-30 mmHg for 2-3 hours 6
• Critical monitoring: Check for supine hypertension (symptoms include headache, pounding in ears, blurred vision, cardiac awareness) 6
• Contraindicated with severe supine hypertension (>180/110 mmHg), severe cardiac disease, or urinary retention 6

Alternative or adjunctive: Fludrocortisone 1, 2

• Start at 0.05-0.1 mg once daily, titrate to 0.1-0.3 mg daily 2
• Acts through sodium retention and vessel wall effects 2
• Monitor for: supine hypertension, hypokalemia, peripheral edema, and heart failure exacerbation 2
• Contraindicated in active heart failure or severe renal disease 2

Alternative: Droxidopa 1, 2

• FDA-approved for neurogenic orthostatic hypotension 2
• Particularly effective in Parkinson's disease, pure autonomic failure, and multiple system atrophy 1, 2

For refractory cases: Pyridostigmine 2

• Consider when first-line treatments fail 2
• Favorable side effect profile compared to alternatives 2
• Common side effects include nausea, abdominal cramping, and sweating 2

Critical Pitfalls to Avoid

• Do not delay assessment of orthostatic vital signs—this is the key diagnostic maneuver. 1, 2
• Do not treat the number alone—treatment is indicated only for symptomatic hypotension or documented orthostatic changes. 1
• Do not overlook medication review—drug-induced hypotension is the most common and most reversible cause. 2
• Do not create supine hypertension—this can cause end-organ damage and is the most important limiting factor in treatment. 2, 6
• Do not use midodrine in patients who will be supine for extended periods—advise patients to skip doses if they cannot remain upright. 6
• Do not combine multiple pressor agents without careful blood pressure monitoring—risk of severe hypertension increases. 6

Follow-Up

Reassess within 1-2 weeks after initiating treatment to evaluate symptom improvement and monitor for supine hypertension. 2 Continue treatment only if patients report significant symptomatic improvement. 6