What are the treatment options for a patient with hypotension?

Treatment for Low Blood Pressure

For symptomatic hypotension, immediately assess the underlying cause and initiate treatment based on whether the patient has acute hemodynamic instability requiring urgent intervention or chronic orthostatic hypotension requiring outpatient management. 1, 2

Acute Hypotension Management

Initial Assessment and Stabilization

• Perform bedside assessment to determine if the patient is hemodynamically stable or unstable by evaluating for signs of end-organ dysfunction (altered mental status, oliguria, cool extremities, elevated lactate). 1
• Measure blood pressure in supine and standing positions after 5 minutes of lying/sitting, then at 1 and 3 minutes after standing. 3, 4
• Unstable patients displaying end-organ dysfunction require high acuity care setting management. 1

Fluid Resuscitation

• Administer crystalloids as first-line therapy with an initial bolus of 30 mL/kg for significant hypotension. 2
• For mild hypotension, give smaller boluses of 5-10 mL/kg of normal saline or balanced crystalloids. 2
• Use passive leg raise (PLR) test to predict fluid responsiveness - an increase in cardiac output after PLR strongly predicts fluid responsiveness (positive likelihood ratio = 11, pooled specificity 92%). 1
• If PLR does not correct hypotension, the problem is not preload-related and requires vasopressor or inotropic support rather than additional fluids. 1
• Continue fluid administration only as long as there is hemodynamic improvement based on dynamic or static variables. 2

Vasopressor Therapy

• Initiate norepinephrine as the first-choice vasopressor if hypotension persists despite adequate fluid resuscitation, targeting a mean arterial pressure (MAP) of 65 mmHg. 2
• For refractory hypotension, add vasopressin (up to 0.03 U/min) or epinephrine to norepinephrine. 2
• Dopamine should only be used in highly selected patients with low risk of tachyarrhythmias or with relative bradycardia. 2
• Phenylephrine is best reserved for situations with hypotension accompanied by tachycardia, as it can cause reflex bradycardia in preload-independent states. 1

Heart Failure-Related Hypotension

• In patients with acute heart failure and hypotension with elevated cardiac filling pressures (elevated JVP, elevated PCWP), administer intravenous inotropic or vasopressor drugs to maintain systemic perfusion. 1
• Inotropes (dobutamine, dopamine, phosphodiesterase III inhibitors) are first-line agents for acute heart failure with severely symptomatic fluid overload. 2
• In persistently hypotensive cardiogenic shock with tachycardia, use norepinephrine. 2

Chronic Orthostatic Hypotension Management

Non-Pharmacological Interventions (First-Line)

All patients should implement non-pharmacological measures before or alongside pharmacological treatment:

• Increase fluid intake to 2-3 liters daily and salt consumption to 6-9 grams daily unless contraindicated by heart failure. 3, 4
• Acute water ingestion of ≥480 mL provides temporary relief with peak effect at 30 minutes, raising systolic BP by >30 mmHg in many patients. 3, 4
• Teach physical counter-maneuvers: leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes, particularly effective in patients under 60 years with prodromal symptoms. 3, 4
• Use compression garments including waist-high compression stockings (30-40 mmHg) and abdominal binders to reduce venous pooling. 3, 4
• Elevate the head of bed by 10 degrees during sleep to prevent nocturnal polyuria, maintain favorable fluid distribution, and ameliorate supine hypertension. 3, 4
• Eat smaller, more frequent meals to reduce postprandial hypotension. 3, 4
• Encourage regular physical activity and exercise to avoid deconditioning, which worsens orthostatic intolerance. 3, 4
• Implement gradual staged movements with postural changes. 3, 4

Medication Review (Critical First Step)

• Discontinue or switch medications that worsen orthostatic hypotension rather than simply reducing doses. 3, 4
• Immediately discontinue alpha-1 blockers (doxazosin, prazosin, terazosin, tamsulosin) as they are the most problematic agents in older adults. 3
• Review and discontinue or reduce diuretics, vasodilators, centrally acting agents (clonidine, methyldopa), and other antihypertensives. 3, 4
• Avoid alcohol as it causes both autonomic neuropathy and central volume depletion. 3

Pharmacological Treatment

When non-pharmacological measures fail to adequately control symptoms, initiate pharmacological treatment with the therapeutic goal of minimizing postural symptoms rather than restoring normotension. 3, 4

First-Line Medications

Midodrine (Preferred First-Line):

• Start with 2.5-5 mg orally three times daily, with the last dose taken at least 3-4 hours before bedtime (not after 6 PM) to prevent supine hypertension during sleep. 3, 4, 5
• Midodrine has the strongest evidence base among pressor agents, with three randomized placebo-controlled trials demonstrating efficacy. 3
• Titrate individually up to 10 mg two to four times daily based on response. 3
• Increases standing systolic BP by 15-30 mmHg for 2-3 hours through alpha-1 adrenergic agonist action causing arteriolar and venous constriction. 3
• Monitor carefully for supine hypertension (BP >200 mmHg systolic possible), which can often be controlled by preventing the patient from becoming fully supine. 5
• Use cautiously with cardiac glycosides, beta-blockers, or other agents that reduce heart rate due to potential vagal reflex bradycardia. 5
• Avoid concomitant use with other vasoconstrictors (phenylephrine, ephedrine, pseudoephedrine, dihydroergotamine). 5

Fludrocortisone (Alternative First-Line):

• Start with 0.05-0.1 mg once daily, titrate to 0.1-0.3 mg daily based on response (maximum 1.0 mg daily). 3, 4
• Acts through sodium retention and vessel wall effects to increase plasma volume. 3
• Contraindicated in patients with active heart failure, significant cardiac dysfunction, or pre-existing supine hypertension. 3
• Monitor for supine hypertension (most important limiting factor), hypokalemia, congestive heart failure, and peripheral edema. 3
• Check electrolytes periodically due to mineralocorticoid effects causing potassium wasting. 3
• Avoid in severe renal disease where sodium retention would be harmful. 3

Droxidopa:

• FDA-approved for neurogenic orthostatic hypotension, particularly effective in Parkinson's disease, pure autonomic failure, and multiple system atrophy. 3, 4
• May reduce falls in these populations. 3

Combination Therapy

• For non-responders to monotherapy, combine midodrine with fludrocortisone as they work through complementary mechanisms (alpha-1 adrenergic stimulation vs. sodium retention). 3
• Ensure adequate salt (6-10g daily) and fluid (2-3L daily) intake as adjunctive measures unless contraindicated by heart failure. 3

Refractory Cases

Pyridostigmine (for refractory orthostatic hypotension):

• Consider pyridostigmine 60 mg orally three times daily (maximum 600 mg daily) for elderly patients with refractory orthostatic hypotension who have failed first-line treatments, particularly those with concurrent supine hypertension. 3, 4
• Preferred when supine hypertension is a concern as it does not worsen supine BP. 3
• Works by inhibiting acetylcholinesterase, enhancing ganglionic sympathetic transmission. 3
• Does not cause fluid retention, making it safer in patients with underlying cardiac dysfunction. 3
• Common side effects include nausea, vomiting, abdominal cramping, sweating, salivation, and urinary incontinence, which are generally manageable. 3

Special Populations

Patients with Both Hypertension and Orthostatic Hypotension:

• Switch BP-lowering medications that worsen orthostatic hypotension to alternative therapy rather than simply reducing doses. 3, 4
• Use long-acting dihydropyridine calcium channel blockers (e.g., amlodipine) or RAS inhibitors as first-line therapy. 3
• Avoid alpha-1 blockers, which are explicitly contraindicated. 3
• Asymptomatic orthostatic hypotension during hypertension treatment should not trigger automatic down-titration, as intensive BP lowering may actually reduce orthostatic hypotension risk by improving baroreflex function. 3

Elderly and Frail Patients (≥85 years):

• Defer BP-lowering treatment until office BP ≥140/90 mmHg in patients with pre-treatment symptomatic orthostatic hypotension, moderate-to-severe frailty, or limited life expectancy. 3
• If BP drops with progressing frailty, consider deprescribing BP-lowering medications and other drugs that reduce BP (sedatives, alpha-blockers). 4
• Target "as low as reasonably achievable" (ALARA principle) rather than strict 130/80 mmHg. 3

Diabetic Patients:

• Assess for cardiovascular autonomic neuropathy. 3, 4
• Consider alpha-lipoic acid for painful diabetic neuropathy, which may benefit autonomic function. 3, 4
• Use midodrine cautiously. 4

Monitoring and Follow-Up

• Reassess within 1-2 weeks after initiating or changing medications. 3, 4
• Measure blood pressure in both supine and standing positions at each visit to balance symptom relief against supine hypertension risk. 3, 4
• Monitor for treatment tolerance, especially supine hypertension with pressor agents and electrolyte abnormalities with fludrocortisone. 3, 4
• Complement MAP targets with other markers of perfusion: lactate, mixed or central venous oxygen saturations, urine output, skin perfusion, and mental status. 2

Critical Pitfalls to Avoid

• Do not delay vasopressor use in cases of significant hypotension unresponsive to fluids - approximately 50% of postoperative hypotensive patients do not respond to fluid boluses. 1, 2
• Do not give fluids to all hypotensive patients reflexively - use PLR test to determine if preload augmentation is needed. 1
• Do not simply reduce doses of offending medications - switch to alternative therapy instead. 3, 4
• Do not administer midodrine after 6 PM to prevent supine hypertension during sleep. 3, 4
• Do not use fludrocortisone in patients with heart failure or supine hypertension. 3, 4
• Do not combine multiple vasodilating agents (ACE inhibitors + calcium channel blockers + diuretics) without careful monitoring. 4
• Do not overlook volume depletion as a contributing factor. 4
• Do not use hydroxyethyl starches due to potential adverse effects. 2
• Do not use beta-blockers unless compelling indications exist, as they can exacerbate orthostatic hypotension. 3