Should blood pressure (BP) medication be stopped in a patient with orthostatic hypotension and referred to a cardiologist?

Management of Orthostatic Hypotension: Medication Adjustment Strategy

Do not routinely stop all BP medications in patients with orthostatic hypotension; instead, systematically switch offending agents to preferred alternatives that minimize orthostatic effects, and only refer to cardiology if symptoms persist despite medication optimization or if there are compelling cardiac indications. 1

Initial Assessment and Confirmation

• Confirm orthostatic hypotension by measuring BP after 5 minutes of lying/sitting, then at 1 and/or 3 minutes after standing (≥20 mmHg systolic or ≥10 mmHg diastolic drop). 1, 2
• Identify all medications contributing to orthostatic hypotension before making changes. 1

Medication Management Algorithm

Step 1: Identify and Eliminate High-Risk Offenders

Medications to discontinue completely (not dose-reduce):

• Alpha-1 blockers (doxazosin, prazosin, terazosin) - these are the highest risk agents and should be eliminated entirely. 1
• Centrally-acting drugs (clonidine, methyldopa, guanfacine) - strongly associated with orthostatic hypotension. 1
• Beta-blockers unless there are compelling indications (heart failure, post-MI, atrial fibrillation) - these interfere with baroreceptor function. 1, 3
• Diuretics causing volume depletion - particularly thiazides in elderly patients. 1

Step 2: Switch to Preferred Antihypertensive Agents

First-line alternatives that minimize orthostatic hypotension:

• Long-acting dihydropyridine calcium channel blockers (amlodipine, nifedipine XL) - recommended as first-line by the European Society of Cardiology for patients with orthostatic hypotension. 1
• RAS inhibitors (ACE inhibitors or ARBs) - have minimal impact on orthostatic BP and should be continued or initiated. 1
• SGLT2 inhibitors - particularly useful in patients with chronic kidney disease (eGFR >20 mL/min/1.73 m²). 1
• Mineralocorticoid receptor antagonists - have minimal orthostatic impact and can be maintained. 1

Step 3: Implement Non-Pharmacological Measures First-Line

• Non-pharmacological approaches are the recommended first-line treatment before considering medication discontinuation. 1, 2
• Specific interventions include: gradual staged movements with postural change, physical counter-maneuvers, increased fluid and salt intake, exercise, physical training, and compression stockings. 1
• Space out medication timing to reduce synergistic hypotensive effects. 1

When to Refer to Cardiology

Refer to cardiology if:

• Symptoms persist despite medication optimization and non-pharmacological measures. 4
• Compelling cardiac indications exist (heart failure, recent MI, complex arrhythmias) that require specialized management. 1
• Severe orthostatic hypotension coexists with supine hypertension requiring complex pharmacological management (midodrine, fludrocortisone, droxidopa). 1, 4
• Patient requires beta-blockers for compelling indications but has severe orthostatic symptoms. 3

Critical Pitfalls to Avoid

• Do not simply reduce doses of offending medications - the European Heart Journal recommends switching to alternative agents rather than dose reduction. 1, 2
• Do not discontinue all antihypertensives - this worsens supine/seated hypertension, which drives adverse cardiovascular events and mortality. 5
• Do not abruptly stop beta-blockers - this causes rebound hypertension; taper gradually if discontinuation is necessary. 3
• Do not assume orthostatic hypotension requires stopping ACE inhibitors/ARBs - these have minimal orthostatic impact and should be continued for patients with heart failure, post-MI, diabetes, or chronic kidney disease. 1

Monitoring After Medication Changes

• Reassess symptoms and orthostatic BP within 1-2 weeks after medication adjustments. 2
• Monitor both standing and supine BP regularly, as supine hypertension may emerge or worsen. 2, 4
• Target symptom relief and fall prevention rather than specific BP numbers. 6