How to manage a patient with hypertension and postural hypotension?

Treatment of Hypertension with Postural Hypotension

For patients with both hypertension and postural hypotension, initiate antihypertensive therapy with long-acting dihydropyridine calcium channel blockers (such as amlodipine) or RAS inhibitors (ACE inhibitors or ARBs), as these agents have minimal orthostatic effects and are specifically recommended by the European Society of Cardiology for this population. 1, 2

Initial Assessment and Documentation

Before starting any antihypertensive therapy, confirm the presence of orthostatic hypotension by measuring blood pressure after 5 minutes of sitting or lying, then at 1 and 3 minutes after standing. 3, 2 Orthostatic hypotension is defined as a drop in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg within 3 minutes of standing. 2, 4, 5

• The ACC/AHA guidelines specifically recommend detecting orthostatic hypotension in selected patients, particularly older adults or those with postural symptoms, before initiating treatment. 3
• Standing blood pressure measurements should be performed in treated hypertensives after 1 minute and again after 3 minutes when symptoms suggest postural hypotension. 3

First-Line Antihypertensive Selection

Preferred agents that minimize orthostatic effects include: 1, 2

• Long-acting dihydropyridine calcium channel blockers (e.g., amlodipine)
• RAS inhibitors (ACE inhibitors like lisinopril or ARBs)
• SGLT2 inhibitors
• Mineralocorticoid receptor antagonists

Avoid or use with extreme caution:

• Alpha-blockers (prazosin, doxazosin, terazosin) can antagonize compensatory mechanisms and worsen orthostatic hypotension 6, 7
• High-dose diuretics may exacerbate volume depletion 8

The European Society of Cardiology specifically recommends switching to these preferred agents rather than simply reducing doses of problematic medications. 2

Dosing Strategy and Titration

Start with lower doses and slower titration than in younger patients without orthostatic hypotension. 1

• For ACE inhibitors like lisinopril, symptomatic postural hypotension should be anticipated in volume and/or salt-depleted patients. 8
• Target systolic blood pressure of 120-129 mmHg if well tolerated, though the KDIGO guidelines suggest clinicians can reasonably offer less intensive BP-lowering therapy in patients with symptomatic postural hypotension. 3, 1
• Reassess within 1-2 weeks after initiating treatment to check for orthostatic symptoms and blood pressure response. 1

Concurrent Management of Orthostatic Hypotension

Non-Pharmacological Measures (First-Line)

Implement these interventions before or alongside antihypertensive therapy: 2, 9, 4, 5

• Increase fluid intake to 2-3 liters daily and salt consumption to 6-9 grams daily (unless contraindicated by heart failure) 2, 10
• Elevate the head of bed by 10 degrees during sleep to prevent nocturnal polyuria and ameliorate nocturnal hypertension 2
• Physical counter-maneuvers: leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes 10, 5
• Compression garments: waist-high compression stockings (30-40 mmHg) and abdominal binders to reduce venous pooling 10, 5

Pharmacological Treatment for Orthostatic Hypotension (If Non-Pharmacological Measures Insufficient)

Midodrine is the first-line pressor agent with the strongest evidence base: 2, 10, 9, 5

• Initial dose: 2.5-5 mg three times daily
• Last dose should be at least 3-4 hours before bedtime to prevent supine hypertension 10, 6
• Use cautiously with cardiac glycosides (may enhance bradycardia), avoid with MAO inhibitors or linezolid 6
• Use cautiously in patients with urinary retention 6

Fludrocortisone is an alternative agent: 2, 10, 9, 5

• Initial dose: 0.05-0.1 mg once daily, titrated to 0.1-0.3 mg daily based on response 2, 10
• Contraindicated in patients with active heart failure, significant cardiac dysfunction, pre-existing supine hypertension, or severe renal disease 2
• Monitor for supine hypertension when used concomitantly with antihypertensive therapy 6, 9

Critical Monitoring and Follow-Up

• Check blood pressure in both supine and standing positions at each visit 3
• For RAS inhibitors or diuretics, assess electrolytes and renal function 2-4 weeks after initiating therapy 3
• Monitor for supine hypertension, particularly if using fludrocortisone or midodrine 6, 9, 5
• Aim to achieve target blood pressure within 3 months to ensure adherence and reduce cardiovascular risk 1

Combination Therapy Approach

If blood pressure remains uncontrolled on monotherapy, add a second agent from a different class (e.g., RAS blocker + calcium channel blocker). 1 The ACC/AHA guidelines note that for stage 2 hypertension (≥140/90 mmHg), consider initiating two antihypertensive agents from different classes. 3

Common Pitfalls to Avoid

• Do not measure blood pressure only in the seated position in patients at risk for orthostatic hypotension—standing measurements are essential 3
• Do not attribute all dizziness to antihypertensive medications—elderly patients have a high baseline incidence of postural symptoms 7
• Do not discontinue antihypertensive therapy without attempting medication optimization—switching drug classes is often more effective than dose reduction 2
• Avoid aggressive blood pressure targets if they worsen orthostatic symptoms and functional status—the treatment goal should prioritize symptom improvement and quality of life over arbitrary blood pressure values 3, 4