From the Guidelines
Postural hypotension is a drop in blood pressure that occurs when changing from lying down to standing up, and its causes include dehydration, prolonged bed rest, aging, certain medications, neurological disorders, endocrine disorders, heart problems, and blood loss or anemia, as stated in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The main causes of postural hypotension can be categorized into several groups, including:
- Dehydration and volume depletion
- Prolonged bed rest and deconditioning
- Aging and frailty
- Certain medications, such as antihypertensives, diuretics, antidepressants, and alpha-blockers
- Neurological disorders, such as Parkinson's disease and multiple system atrophy
- Endocrine disorders, such as diabetes and adrenal insufficiency
- Heart problems, such as heart failure and arrhythmias
- Blood loss or anemia To investigate postural hypotension, several tests should be performed, including:
- Orthostatic vital sign measurements (blood pressure and heart rate while lying, sitting, and standing)
- Complete blood count to check for anemia
- Basic metabolic panel to assess electrolytes and kidney function
- Blood glucose testing
- ECG to evaluate cardiac function
- Possibly autonomic function tests In some cases, additional specialized tests may be needed, such as:
- Tilt-table testing
- Catecholamine levels
- Adrenal function tests
- Neurological imaging if a central nervous system cause is suspected The investigation should also include a thorough medication review to identify potential drug-related causes, as medication adjustment is often the simplest intervention, as recommended in the 2021 standards of medical care in diabetes 1. The diagnosis of postural hypotension is made in the office, and routine ABPM is not currently suitable for formally assessing orthostatic hypotension, though it may help in some cases, particularly when accompanied by a patient symptom diary, as stated in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. Classical orthostatic hypotension is defined as a sustained decrease in systolic BP >_20 mmHg, diastolic BP >_10 mmHg, or a sustained decrease in systolic BP to an absolute value <90 mmHg within 3 min of active standing or head-up tilt of at least 60 degrees, as described in the 2018 ESC guidelines for the diagnosis and management of syncope 1. The treatment of postural hypotension includes nonpharmacologic measures, such as ensuring adequate salt intake, avoiding medications that aggravate hypotension, and using compressive garments over the legs and abdomen, as well as pharmacologic measures, such as midodrine and droxidopa, which are approved by the FDA for the treatment of orthostatic hypotension, as stated in the 2021 standards of medical care in diabetes 1.
From the Research
Causes of Postural Hypotension
- Orthostatic hypotension (OH) is considered a manifestation of dysfunction of the autonomic nervous system, caused or facilitated by several neurological or non-neurological diseases and conditions 2
- It is highly prevalent in elderly and frail individuals and in patients with multiple comorbidities 2
- The clinical significance of OH is increasingly recognized as a cause of impairment of quality of life and potentially of worse outcomes, including coronary artery disease, heart failure, stroke, cognitive dysfunction, and mortality rates 2
Investigations Needed
- Diagnosis of OH involves assessing blood pressure fall when standing from the supine to the erect position 2
- Evaluation of the literature on oral and intravenous hydration in the treatment of neurogenic orthostatic hypotension, postural tachycardia syndrome, and recurrent vasovagal syncope is necessary 3
- Assessment of intravascular volume and cerebral perfusion may be necessary to determine the best course of treatment 3
- Patients with excessive renal sodium excretion or hypovolemia may require oral salt replacement or intravenous volume-loading 3