How to manage hypotension (low blood pressure)?

Management of Low Blood Pressure

Asymptomatic low blood pressure does not require treatment in most cases; focus on assessing end-organ perfusion and symptoms rather than treating numbers alone. 1

Critical Assessment Framework

Immediate Triage Based on Severity

Severe hypotension (systolic BP <80 mmHg) requires emergency intervention regardless of symptoms due to risk of organ hypoperfusion and cardiovascular collapse. 2, 1

For severe hypotension:

• Establish IV access immediately and initiate continuous vital sign monitoring 1
• Start norepinephrine (0.1-0.5 mcg/kg/min IV) as first-line vasopressor, targeting mean arterial pressure ≥65 mmHg 1
• Assess for end-organ damage: altered mental status, decreased urine output (<0.5 mL/kg/hr), elevated lactate, cool extremities 1

Symptomatic vs. Asymptomatic Low BP

For systolic BP 80-100 mmHg, management depends entirely on symptoms and perfusion status, not the number itself. 1, 3

Major symptoms requiring intervention include: 2

• Significant orthostatic hypotension with dizziness
• Severe fatigue or weakness limiting activities
• Syncope or near-syncope
• Signs of hypoperfusion (confusion, oliguria, chest pain)

Asymptomatic low BP or mild transient dizziness does NOT warrant medication adjustment in stable patients. 2, 3

Context-Specific Management

In Heart Failure with Reduced Ejection Fraction (HFrEF)

Do NOT reduce or discontinue guideline-directed medical therapy (GDMT) for asymptomatic or mildly symptomatic low BP in stable HFrEF patients. 2, 1

This is a critical pitfall: patients stable on optimal GDMT who develop low BP are unlikely to have it caused by their HF medications—investigate other causes first. 2

Algorithm for HFrEF patients with low BP:

1. First, assess congestion status (clinical exam, lung ultrasound, biomarkers) 2

   • If no congestion present: cautiously reduce diuretics 2
   • If congested: maintain current therapy

2. Review and discontinue non-GDMT medications that lower BP: 2

   • Alpha-blockers for benign prostatic hyperplasia
   • Nitrates (unless active angina)
   • Other antihypertensives not indicated for HF

3. If initiating or up-titrating GDMT in patients with baseline low BP: 2

   • Start SGLT2 inhibitors and mineralocorticoid receptor antagonists (MRAs) first—these do not lower BP and may actually increase it 2, 1
   • Then add low-dose beta-blocker if heart rate >70 bpm, OR low-dose ARNI/ACE inhibitor/ARB 2
   • Up-titrate one drug at a time with small increments every 1-2 weeks 2
   • If beta-blocker not tolerated and patient in sinus rhythm, use ivabradine 2
   • If atrial fibrillation with uncontrolled rate, consider digoxin (does not lower BP) 2, 4

4. Only reduce GDMT if: 2, 1

   • Systolic BP <80 mmHg persists
   • Major symptoms develop despite above measures
   • Evidence of end-organ hypoperfusion

Critical caveat: Discontinuing GDMT due to side effects causes worse outcomes than the side effects themselves. 2

In Orthostatic Hypotension

Orthostatic hypotension is defined as a drop ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing. 1, 5, 6

Diagnosis requires measuring BP after 5 minutes supine/sitting, then at 1 and 3 minutes after standing. 1, 5

Treatment is indicated only when orthostatic hypotension causes symptoms that impair quality of life. 1, 6

Management algorithm:

1. Non-pharmacologic measures (offer to all patients): 5, 6, 7

   • Discontinue or reduce blood pressure-lowering medications when possible
   • Increase fluid intake (2-2.5 L/day) and salt intake (6-10 g/day)
   • Compression stockings (waist-high, 30-40 mmHg)
   • Physical counterpressure maneuvers (leg crossing, squatting, muscle tensing)
   • Elevate head of bed 10-20 degrees to reduce nocturnal diuresis
   • Rise slowly from supine/sitting positions
   • Avoid prolonged standing, hot environments, large meals, alcohol

2. Pharmacologic treatment (if non-pharmacologic measures insufficient): 5, 6

   • Fludrocortisone 0.1-0.2 mg daily (volume expansion via mineralocorticoid effect) 5, 6
   • Midodrine 2.5-10 mg three times daily (alpha-agonist, increases vascular tone) 8, 5, 6
     • Critical warning: Take last dose 3-4 hours before bedtime to avoid supine hypertension 8
     • Monitor for supine hypertension (BP >200 mmHg systolic possible) 8
     • Contraindicated in severe coronary disease, acute renal failure, urinary retention, pheochromocytoma 8
   • Pyridostigmine 30-60 mg three times daily (alternative option) 5

Goal of treatment: symptom relief and fall prevention, NOT achieving specific BP targets. 6

In Patients with Baseline Hypertension

In patients with chronic hypertension who develop acute low BP, reduce BP cautiously to avoid organ hypoperfusion. 1

For acute ischemic stroke: only treat if BP >220/120 mmHg; reduce mean arterial pressure by 15% over 1 hour (unless thrombolysis planned, then target <185/110 mmHg). 1

Special High-Risk Conditions

Low BP is particularly detrimental in these conditions—requires multidisciplinary management: 2

• Significant peripheral vascular disease with non-healing ulcers
• Bilateral untreated carotid stenosis
• Recent stroke or transient ischemic attack
• Bowel ischemia or abdominal angina
• End-stage renal disease on dialysis
• Autonomic dysfunction

Common Pitfalls to Avoid

1. Do NOT treat asymptomatic low BP numbers alone—assess organ perfusion and symptoms first. 1, 3

2. Do NOT discontinue HF medications prematurely in stable patients with low BP—investigate other causes first (valvular disease, myocardial ischemia, new medications like alpha-blockers). 2, 3

3. Do NOT use beta-blockers to treat hypotension—they lower BP further. 1

4. Do NOT measure BP only in sitting position—always check standing BP to detect orthostatic component (missed in up to 30% of cases otherwise). 1, 4, 5

5. Do NOT focus solely on diastolic BP in the 50s—this alone is NOT an indication to reduce therapy in HFrEF patients. 4

6. Do NOT abruptly withdraw antihypertensive medications—can cause rebound hypertension. 3

7. In patients taking midodrine, do NOT forget to monitor for supine hypertension—measure both standing and supine BP regularly. 1, 8

Monitoring After Intervention

For acute severe hypotension requiring vasopressors: 1

• Continuously monitor BP, heart rate, urine output, mental status, lactate clearance
• Target mean arterial pressure ≥65 mmHg
• Reassess volume status and underlying cause

For chronic orthostatic hypotension on treatment: 1, 5

• Regular follow-up to assess symptom improvement
• Monitor both standing and supine BP to detect supine hypertension
• Educate patients about symptoms to report (worsening dizziness, syncope, headache from supine hypertension)

For HFrEF patients with low BP on GDMT: 2

• Close observation during up-titration (every 1-2 weeks)
• Monitor renal function, potassium, symptoms
• Reassess congestion status regularly
• Sometimes BP improves as cardiac output increases with optimized therapy 2