Management of Hypotension
Immediate Assessment and Acute Intervention
For patients presenting with acute hypotension and signs of hypoperfusion (decreased urine output, altered mental status, shock), intravenous vasopressors or inotropic agents should be administered immediately to maintain systemic perfusion and preserve end-organ function while identifying the underlying cause. 1
Acute Hypotension in Critical Settings
Phenylephrine (alpha-1 adrenergic agonist) is indicated for clinically important hypotension in anesthesia and septic shock settings, with initial intravenous bolus dosing of 50-250 mcg or continuous infusion of 0.5-1.4 mcg/kg/minute titrated to effect. 2
Ephedrine sulfate is recommended for hypotension during anesthesia at an initial dose of 5-10 mg intravenous bolus, with additional boluses as needed up to 50 mg total, titrated to blood pressure goals. 3
In heart failure patients with hypotension and hypoperfusion despite elevated cardiac filling pressures (elevated jugular venous pressure, elevated pulmonary artery wedge pressure), intravenous inotropic or vasopressor drugs are necessary while definitive therapy is considered. 1
Identifying the Underlying Cause
Rapidly evaluate for shock states (cardiogenic, distributive, hypovolemic, obstructive), acute myocardial infarction, pulmonary embolism, infections, renal failure, or medication effects as reversible causes requiring immediate intervention. 1
For endocrine causes, consider adrenal insufficiency (primary or secondary), isolated hypoaldosteronism, pheochromocytoma crisis during surgical removal, or carcinoid syndrome with flushing episodes—all require specific hormonal replacement or targeted therapy. 4
Chronic Hypotension Management
Orthostatic Hypotension in Hypertensive Patients
Before starting or intensifying blood pressure-lowering medications, test for orthostatic hypotension by measuring blood pressure after 5 minutes of sitting/lying, then at 1 and/or 3 minutes after standing. 1
Non-Pharmacologic First-Line Approaches
Pursue non-pharmacological strategies as first-line treatment for orthostatic hypotension, especially in patients with supine hypertension, rather than simply reducing antihypertensive therapy. 1
Implement physical countermaneuvers (leg crossing, muscle tensing, squatting) to acutely raise blood pressure during symptomatic episodes. 5
Ensure adequate hydration and salt intake (increase sodium to 6-10 g/day unless contraindicated), elevate head of bed 10-20 degrees to reduce nocturnal diuresis, and use compression stockings (waist-high, 30-40 mmHg). 6, 5
Educate patients to rise slowly from supine/sitting positions, avoid prolonged standing, stay well-hydrated, and recognize triggers (hot environments, large meals, alcohol). 6
Medication Optimization Strategy
Switch blood pressure-lowering medications that worsen orthostatic hypotension to alternative agents rather than simply de-intensifying therapy—this maintains blood pressure control while addressing orthostatic symptoms. 1
Review and remove aggravating non-antihypertensive medications: alpha-blockers for prostate symptoms, sedatives, tricyclic antidepressants, and other drugs that can reduce blood pressure. 1, 5
Optimize the antihypertensive regimen by preferring long-acting dihydropyridine calcium channel blockers or RAS inhibitors over agents more likely to cause orthostatic hypotension (alpha-blockers, non-selective beta-blockers, centrally-acting agents). 1
Pharmacologic Treatment for Refractory Cases
When non-pharmacologic measures fail, consider short-acting vasoactive agents:
- Midodrine (alpha-1 agonist): 2.5-10 mg three times daily, taken during daytime hours only to avoid supine hypertension
- Droxidopa (synthetic norepinephrine precursor): 100-600 mg three times daily 5
Fludrocortisone 0.1-0.2 mg daily can be used for volume expansion in patients without heart failure or significant supine hypertension, though it requires careful monitoring for fluid overload and hypokalemia. 6, 5
Special Populations and Contexts
Elderly and Frail Patients
For patients aged ≥85 years or with moderate-to-severe frailty, consider initiating blood pressure treatment with long-acting dihydropyridine calcium channel blockers or RAS inhibitors, followed by low-dose diuretics if tolerated, avoiding beta-blockers or alpha-blockers unless compelling indications exist. 1
If blood pressure drops with progressing frailty, consider deprescribing blood pressure-lowering medications and other drugs that reduce blood pressure (sedatives, prostate-specific alpha-blockers). 1
Pregnancy-Related Hypotension
- In pregnant women with chronic or gestational hypertension, lower blood pressure below 140/90 mmHg but not below 80 mmHg diastolic to avoid fetal hypoperfusion. 1
Chronic Constitutional Hypotension
For young patients with chronic low blood pressure and symptoms (fatigue, dizziness, poor concentration), consider ambulatory blood pressure monitoring to document mean pressure levels and identify marked hypotensive episodes that may not be captured by office measurements. 7
Address vagally mediated syncope in young patients through education about triggers, adequate hydration, increased salt intake, and physical countermaneuvers rather than pharmacologic intervention as first-line. 7
Critical Monitoring Parameters
In acute settings with vasopressor use, monitor fluid intake/output, vital signs, body weight daily, and serum electrolytes, urea nitrogen, and creatinine concentrations during active titration. 1
For chronic orthostatic hypotension treatment, measure both supine and standing blood pressures to balance symptom relief against avoiding excessive supine hypertension (target standing systolic >90 mmHg without supine systolic >180 mmHg). 6, 5
When using mineralocorticoid therapy (fludrocortisone), monitor for peripheral edema, hypokalemia, and supine hypertension at 2-4 week intervals initially. 6
Common Pitfalls to Avoid
Do not discontinue all antihypertensive medications in patients with both hypertension and orthostatic hypotension—this creates uncontrolled supine/seated hypertension with associated cardiovascular risk. 1, 5
Do not assume intensive blood pressure treatment causes orthostatic hypotension in most patients with essential hypertension—evidence shows it does not, though certain drug classes may unmask underlying autonomic impairment. 5
Do not use short-acting vasoactive agents (midodrine, droxidopa) as monotherapy—they must be combined with comprehensive non-pharmacologic strategies for optimal outcomes. 6, 5
Do not administer midodrine or droxidopa within 4 hours of bedtime to avoid severe supine hypertension during sleep. 6, 5