Do compression socks help with orthostatic (postural) hypotension?

From the Guidelines

Yes, compression socks can help with orthostatic hypotension, as they are recommended as a non-pharmacological first-line treatment for managing this condition. Compression socks work by applying graduated pressure to the legs, with the highest pressure at the ankles and decreasing pressure moving up the leg. This mechanical compression helps prevent blood pooling in the lower extremities and improves venous return to the heart, which increases cardiac output and helps maintain blood pressure when standing. For orthostatic hypotension, medical-grade compression socks with 30-40 mmHg pressure are typically most effective, though 20-30 mmHg may be sufficient for milder cases. Patients should put them on first thing in the morning before getting out of bed when blood hasn't yet pooled in the legs. The socks should extend at least to the knee, though thigh-high or waist-high options may provide additional benefit for some patients. Compression socks work best when combined with other measures like adequate hydration, salt intake as medically appropriate, and physical countermaneuvers like muscle tensing when changing positions. While generally safe, patients with peripheral vascular disease, severe heart failure, or skin conditions should consult their healthcare provider before using compression therapy, as supported by the guidelines from the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society 1.

Some key points to consider when using compression socks for orthostatic hypotension include:

• The pressure gradient of the socks, with higher pressure at the ankles and decreasing pressure up the leg
• The duration of wear, typically 8-12 hours a day, and the frequency of wear, at least 3 days a week
• The importance of combining compression socks with other management strategies, such as adequate hydration and physical countermaneuvers
• The potential benefits of thigh-high or waist-high options for some patients
• The need for patients with certain medical conditions to consult their healthcare provider before using compression therapy, as noted in the guidelines 1.

It's also worth noting that more recent studies, such as those from 2024, provide additional guidance on the use of compression garments for managing postthrombotic syndrome, which may be relevant to the use of compression socks for orthostatic hypotension 1. However, the most recent and highest quality study on this topic is from 2017, which provides the basis for the current recommendations 1.

From the Research

Compression Socks and Orthostatic Hypotension

• Compression socks can be used as a non-pharmacological therapeutic option for orthostatic hypotension (OH) 2.
• A systematic review found that full-length compression and compression of solely the abdomen were superior to knee-length and thigh-length compression in reducing the fall in systolic blood pressure after postural change 3.
• The review also found that symptoms of orthostatic hypotension were improved the most by full-length compression 3.
• However, the quality of studies was heterogenous and generally poor, and further investigation is warranted 3.
• A study on patient and physician perspectives and practices found that elastic compression stockings (ECS) are often limited by issues related to practicality, such as difficulty in application and discomfort 2.
• Physicians correctly predicted the main reasons for non-compliance, but underestimated the scale of patient compliance with ECS 2.

Treatment of Orthostatic Hypotension

• Non-pharmacological strategies, such as dietary modifications and compression garments, are the primary treatment for orthostatic hypotension 4, 5.
• Pharmacological strategies, such as midodrine and droxidopa, can be used if non-pharmacological strategies fail 4, 5.
• Fludrocortisone can also be used, but its long-term effects are concerning 4, 6.
• The treatment of orthostatic hypotension should be guided by patient-specific factors, such as tolerability, adverse effects, and drug-drug and drug-disease interactions 5.