From the Guidelines
To perform orthostatic blood pressure checks, have the patient rest in the sitting or lying position for 5 minutes, then measure their blood pressure at 1 min and/or 3 min after standing, with a threshold for orthostatic hypotension of ≥20/10 mmHg (systolic BP/diastolic BP) drop. This is based on the most recent guidelines from the European Heart Journal, as stated in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
Key Steps for Orthostatic Blood Pressure Checks
- Have the patient rest in the sitting or lying position for 5 minutes to ensure accurate baseline readings.
- Measure the patient's blood pressure at 1 min and/or 3 min after standing to assess for orthostatic hypotension.
- Use a properly calibrated blood pressure cuff of appropriate size for accurate readings.
- The patient should avoid eating, drinking caffeine, smoking, or exercising for 30 minutes before the test to minimize potential interference with the results.
Importance of Orthostatic Blood Pressure Checks
Orthostatic blood pressure checks are crucial for diagnosing orthostatic hypotension, which can cause dizziness, lightheadedness, or fainting when standing up, as noted in the guidelines 1. This condition occurs because blood pools in the lower extremities upon standing, and if the body's compensatory mechanisms (like increased heart rate and vasoconstriction) don't work properly, blood pressure drops significantly.
Clinical Considerations
Before starting or intensifying BP-lowering medication, it is recommended to test for orthostatic hypotension, by first having the patient sit or lie for 5 min and then measuring BP 1 and/or 3 min after standing, as recommended in the guidelines 1. Non-pharmacological approaches should be pursued as the first-line treatment of orthostatic hypotension among persons with supine hypertension. For such patients, it is also recommended to switch BP-lowering medications that worsen orthostatic hypotension to an alternative BP-lowering therapy and not to simply de-intensify therapy.
From the Research
Orthostatic Blood Pressure Checks
To perform orthostatic blood pressure checks, the following steps can be taken:
- Measure blood pressure in the supine and standing positions, or alternatively, in the seated and standing positions, although the latter may produce smaller depressor responses due to reduced gravitational stress 2
- Concomitantly measure heart rate responses to standing to assess the integrity of baroreflex function 2
- Define orthostatic hypotension as a sustained reduction in systolic blood pressure > 20 mm Hg or diastolic blood pressure > 10 mm Hg within 3 minutes of standing or > 60° head-up tilt 2, 3
- Be aware that orthostatic hypotension can be asymptomatic, but patients may present with symptoms of cerebral hypoperfusion on standing, predisposing to syncope and falls 2
Key Considerations
- Orthostatic hypotension is a common finding, particularly in elderly populations, and is associated with cardiovascular and cerebrovascular morbidity and mortality 2, 3
- Medications can be a major contributor to orthostatic hypotension, and a medication review is advisable in all patients presenting with orthostatic hypotension, particularly at advanced age 4
- Treatment of orthostatic hypotension should be initiated in a structured and stepwise approach, starting with nonpharmacological interventions and adding pharmacological interventions as needed 2, 5
Diagnostic Criteria
- Orthostatic hypotension can be diagnosed based on a drop in blood pressure of at least 20mmHg for systolic blood pressure and at least 10mmHg for diastolic blood pressure within 3 minutes of standing up 3
- The diagnosis of orthostatic hypotension requires blood pressure measurements in the supine and standing positions, or alternatively, in the seated and standing positions 2