What is the best management approach for a patient in their 60s with a history of hypertension (high blood pressure) and hypotension (low blood pressure)?

Management of Coexisting Hypertension and Hypotension in a Patient in Their 60s

For a patient in their 60s with both hypertension and orthostatic hypotension, the priority is to switch—not simply reduce—blood pressure medications that worsen orthostatic symptoms to long-acting dihydropyridine calcium channel blockers or RAS inhibitors (ACE inhibitors/ARBs), while implementing non-pharmacological measures for orthostatic hypotension. 1, 2

Initial Diagnostic Assessment

Confirm orthostatic hypotension by measuring blood pressure after 5 minutes of sitting/lying, then at 1 and 3 minutes after standing. 1, 2 A drop of ≥20 mmHg systolic or ≥10 mmHg diastolic defines orthostatic hypotension. 1

Identify reversible causes including:

• Medication-induced hypotension (most common cause): alpha-1 blockers (doxazosin, prazosin, terazosin, tamsulosin), diuretics causing volume depletion, centrally-acting agents (clonidine, methyldopa), vasodilators (hydralazine, minoxidil), and beta-blockers. 1, 2
• Volume depletion: excessive diuretic use, inadequate fluid intake, alcohol abuse. 3, 1
• Secondary hypertension: renal artery stenosis, primary aldosteronism, obstructive sleep apnea. 3

Medication Management Strategy

Discontinue or Switch Problematic Agents

The European Society of Cardiology explicitly states to switch BP-lowering medications that worsen orthostatic hypotension to alternative therapy—not simply reduce the dose. 1, 2 This is critical because dose reduction fails to address the mechanistic problem.

Medications to discontinue immediately:

• Alpha-1 blockers (doxazosin, prazosin, terazosin, tamsulosin)—strongly associated with orthostatic hypotension, especially in older adults. 1, 2
• Beta-blockers unless compelling indications exist (heart failure, post-MI, atrial fibrillation). 1, 2
• High-dose or multiple diuretics causing volume depletion. 1, 2
• Centrally-acting agents (clonidine, methyldopa). 2

Preferred Antihypertensive Agents

First-line therapy for patients with both conditions:

Long-acting dihydropyridine calcium channel blockers (amlodipine, nifedipine XL) are the preferred first choice, as they have minimal impact on orthostatic blood pressure and are specifically recommended by the European Society of Cardiology for elderly/frail patients with orthostatic hypotension. 1, 2

RAS inhibitors (ACE inhibitors like lisinopril or ARBs) are equally appropriate as first-line agents with minimal orthostatic effects. 1, 2, 4 ACE inhibitors are particularly beneficial if the patient has heart failure, diabetes, or chronic kidney disease. 4

SGLT2 inhibitors can be considered if the patient has chronic kidney disease (eGFR >20 mL/min/1.73 m²) or diabetes, as they have modest BP-lowering effects with minimal orthostatic impact. 2

Mineralocorticoid receptor antagonists (spironolactone, eplerenone) have minimal impact on orthostatic blood pressure and are particularly useful for resistant hypertension. 3, 2

Target Blood Pressure

For patients in their 60s, target BP <130/80 mmHg based on the 2024 ESC guidelines and 2017 ACC/AHA guidelines. 3 However, the therapeutic goal for orthostatic hypotension is minimizing postural symptoms, not restoring normotension. 1 This requires balancing supine/seated BP control against standing BP tolerance.

Non-Pharmacological Management of Orthostatic Hypotension

Implement these measures as first-line treatment:

Fluid and salt intake:

• Increase fluid intake to 2-3 liters daily (unless contraindicated by heart failure). 1
• Increase salt intake to 6-9 grams daily (unless contraindicated by heart failure). 1

Physical counter-maneuvers:

• Teach leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes—particularly effective in patients under 60 years with prodromal symptoms. 1

Compression garments:

• Waist-high compression stockings (30-40 mmHg) and abdominal binders reduce venous pooling. 1

Postural modifications:

• Elevate head of bed by 10 degrees during sleep to prevent nocturnal polyuria and ameliorate nocturnal hypertension. 1
• Gradual staged movements with postural changes. 1
• Acute water ingestion (≥480 mL) provides temporary relief with peak effect at 30 minutes. 1

Dietary modifications:

• Smaller, more frequent meals to reduce postprandial hypotension. 1

Physical activity:

• Encourage regular exercise to avoid deconditioning, which worsens orthostatic intolerance. 1

Pharmacological Treatment for Persistent Orthostatic Hypotension

If non-pharmacological measures fail to control orthostatic symptoms:

Midodrine (alpha-1 agonist) is the first-line medication with the strongest evidence base—three randomized placebo-controlled trials demonstrate efficacy. 1

• Dosing: Start 2.5-5 mg three times daily, titrate up to 10 mg three times daily as needed. 1
• Critical timing: Last dose must be at least 3-4 hours before bedtime (not after 6 PM) to prevent supine hypertension during sleep. 1
• Mechanism: Increases standing systolic BP by 15-30 mmHg for 2-3 hours through arteriolar and venous constriction. 1

Fludrocortisone (mineralocorticoid) can be added if midodrine alone is insufficient:

• Dosing: Start 0.05-0.1 mg once daily, titrate to 0.1-0.3 mg daily. 1
• Mechanism: Increases plasma volume through sodium retention and vessel wall effects. 1
• Monitoring: Check for supine hypertension, hypokalemia, congestive heart failure, and peripheral edema. 1
• Contraindications: Active heart failure, severe renal disease, pre-existing supine hypertension. 1

Droxidopa is FDA-approved and particularly effective for neurogenic orthostatic hypotension (Parkinson's disease, pure autonomic failure, multiple system atrophy). 1

Pyridostigmine (60 mg three times daily) is beneficial for refractory cases, especially when supine hypertension is a concern, as it does not worsen supine BP. 1 It has a favorable side effect profile compared to alternatives. 1

Monitoring Protocol

At each visit:

• Measure both supine/seated and standing BP (after 5 minutes lying/sitting, then at 1 and 3 minutes after standing). 1
• Monitor for supine hypertension development, which can cause end-organ damage. 1
• Assess symptom improvement and functional capacity. 1

After medication changes:

• Reassess within 1-2 weeks. 1
• If adding fludrocortisone, check electrolytes, BUN, and creatinine periodically. 1

Home blood pressure monitoring is recommended to achieve better BP control and assess both supine and standing values in the patient's usual environment. 3, 5, 6, 7

Common Pitfalls to Avoid

Do not simply reduce the dose of medications worsening orthostatic hypotension—switch to alternative agents. 1, 2

Do not combine multiple vasodilating agents (ACE inhibitors + calcium channel blockers + diuretics) without careful monitoring. 1

Do not overlook volume depletion as a contributing factor—assess fluid status and diuretic dosing. 1

Do not administer midodrine after 6 PM due to risk of nocturnal supine hypertension. 1

Do not use fludrocortisone in patients with heart failure or supine hypertension. 1

Avoid beta-blockers unless compelling indications exist, as they can exacerbate orthostatic hypotension. 1, 2

When to Refer to Specialist

Refer to hypertension specialist if:

• BP remains uncontrolled despite optimized triple therapy (CCB + RAS inhibitor + diuretic). 8
• Secondary hypertension is suspected. 8

Refer to cardiology/autonomic specialist if:

• Orthostatic hypotension persists despite medication optimization and non-pharmacological measures. 1
• Suspected neurogenic orthostatic hypotension requiring advanced testing. 1