What are the treatment options for hypotension (low blood pressure)?

Treatment for Low Blood Pressure

Treatment of hypotension depends critically on whether you have symptoms and the underlying cause—asymptomatic low blood pressure requires no intervention, while symptomatic hypotension demands immediate assessment of organ perfusion and targeted therapy. 1

Initial Assessment: Determine If Treatment Is Needed

First, verify the blood pressure readings and assess for symptoms:

• Measure BP after the patient sits or lies for 5 minutes, then remeasure at 1 and/or 3 minutes after standing to detect orthostatic hypotension (drop of ≥20 mmHg systolic or ≥10 mmHg diastolic) 2, 3
• If symptoms (dizziness, syncope, fatigue) correlate with confirmed orthostatic hypotension, this is symptomatic hypotension requiring treatment 2, 1
• Consider ambulatory blood pressure monitoring if office measurements don't identify symptomatic hypotension 2
• Critical threshold: Systolic BP <80 mmHg or hypotension causing major symptoms warrants immediate attention 2, 1

Key principle: Hypotension with minor symptoms is NOT a reason to withhold treatment or reduce medications for other conditions like heart failure 2

Non-Pharmacologic Treatment (First-Line for Chronic Orthostatic Hypotension)

Start with lifestyle modifications before considering medications:

• Support stockings to reduce venous pooling 4, 5
• Fluid expansion—increase total fluid intake 4, 5
• Physical countermaneuvers (leg crossing, squatting) when symptoms occur 5
• Paradoxically, avoid adding salt to water when drinking—plain water (473 mL/16 oz) increases systolic BP by >30 mmHg in orthostatic hypotension patients, but adding salt attenuates this gastropressor response 6

Pharmacologic Treatment for Symptomatic Orthostatic Hypotension

Medications should only be used when lives are considerably impaired despite standard clinical care:

FDA-Approved Agents

• Midodrine (first-line pharmacologic agent): Start 10 mg three times daily, with last dose not later than 6 PM to avoid supine hypertension 4

  • Increases standing systolic BP by approximately 15-30 mmHg at 1 hour after dosing, with effects persisting 2-3 hours 4
  • Works via alpha-1 agonist activity on arteriolar and venous vasculature 4
  • Warning: Can cause marked supine hypertension (>200 mmHg systolic in 22% of patients on 10 mg dose) 4
  • Continue only if patients report significant symptomatic improvement 4

• Droxidopa: FDA-approved alternative for orthostatic hypotension 1

Treatment Goal

• Goal is to improve postural symptoms, standing time, and function—NOT to achieve upright normotension 1
• Focus on functional improvement rather than arbitrary BP targets 5

Acute Hypotension Management (Emergency/Perioperative Settings)

Before reflexively giving fluids, determine the cause:

Step 1: Assess Fluid Responsiveness

• Perform passive leg raise (PLR) test BEFORE administering fluids 3
  • PLR has 92% specificity and positive likelihood ratio of 11 for predicting fluid response 7, 3
  • If cardiac output increases with PLR → patient will respond to fluids (give 250-500 mL bolus) 3
  • If no increase in cardiac output with PLR → patient needs vasopressors or inotropes, NOT fluids 3
• Critical pitfall: Approximately 50% of hypotensive patients are NOT hypovolemic—reflexive fluid administration without assessment is dangerous 7, 3

Step 2: Cause-Directed Treatment

For vasodilation (distributive shock):

• Norepinephrine is first-line vasopressor 3
• Phenylephrine preferred when hypotension occurs with tachycardia (causes reflex bradycardia) 3

For hypovolemia (only if PLR positive):

• Crystalloid, colloid, or blood products as appropriate 3
• Pediatric dosing: 10-20 mL/kg normal saline (maximum 1,000 mL) 3
• Avoid additional fluids if cardiac dysfunction or pulmonary edema present 3

Blood Pressure Targets in Acute Settings

• Maintain mean arterial pressure (MAP) ≥60 mmHg in at-risk surgical patients 3
• MAP <60-70 mmHg or systolic BP <90-100 mmHg is associated with acute kidney injury, myocardial injury, and death 3
• Exception—trauma without brain injury: Use restricted volume replacement targeting systolic BP 80-90 mmHg (MAP 50-60 mmHg) until bleeding is controlled 3
• Exception—severe traumatic brain injury: Maintain MAP ≥80 mmHg for adequate cerebral perfusion 7, 3

Special Population: Heart Failure with Reduced Ejection Fraction

Asymptomatic or mildly symptomatic low BP should NOT prevent guideline-directed medical therapy (GDMT):

• Start with SGLT2 inhibitors and mineralocorticoid receptor antagonists (MRAs)—these have minimal BP effects and may actually increase BP in low BP groups 1
• Continue beta-blockers and ACE inhibitors/ARBs unless systolic BP <80 mmHg or major symptoms present 2
• Consider digoxin for patients with atrial fibrillation and elevated heart rate where GDMT optimization is limited by low BP (digoxin does not decrease BP) 2

Critical Pitfalls to Avoid

• Never give fluids reflexively without PLR test—half of hypotensive patients need vasopressors, not volume 7, 3
• Postoperative hypotension is often unrecognized and untreated—may be more important than intraoperative hypotension because it is prolonged 3
• Do not withhold heart failure medications for asymptomatic low BP—focus on organ perfusion, not BP numbers 2, 1
• Avoid abrupt withdrawal of vasopressor infusions—reduce gradually 3