What are the management strategies for an adult patient with a history of hypertension or cardiovascular disease experiencing hypotension?

Management of Hypotension in Adults with Hypertension or Cardiovascular Disease

In hypertensive patients experiencing hypotension, immediately assess for acute end-organ damage to distinguish hypertensive emergency from urgency, hold or reduce antihypertensive medications, evaluate for orthostatic hypotension, and address reversible causes before considering vasopressor support. 1, 2

Initial Assessment and Triage

Distinguish Emergency from Urgency

• Hypertensive emergency (BP >180/120 mmHg WITH acute end-organ damage) requires ICU admission with IV titratable agents like labetalol or nicardipine, NOT oral captopril 1, 2, 3
• Asymptomatic hypertensive urgency (severe BP elevation WITHOUT organ damage) should be managed with oral medications and outpatient follow-up within 24-48 hours—rapid BP reduction is unnecessary and potentially harmful 2, 3
• Many patients with acute pain or distress have transiently elevated BP that normalizes when the underlying stressor is addressed, requiring no specific antihypertensive intervention 2

Evaluate for Orthostatic Hypotension

• Measure BP after 5 minutes supine/sitting, then at 1 and 3 minutes after standing before initiating or intensifying antihypertensive therapy 1
• Orthostatic hypotension is an independent predictor of cardiovascular mortality and all-cause mortality, particularly in older patients 4, 5
• In patients with pre-existing symptomatic orthostatic hypotension, BP-lowering treatment should only be considered if office BP ≥140/90 mmHg, with close monitoring 1

Medication Management Strategy

Immediate Actions for Hypotension

• Hold or reduce antihypertensive medications when patients present with hypotension, especially if associated with decreased oral intake, vomiting, diarrhea, or volume depletion 1
• Switch BP-lowering medications that worsen orthostatic hypotension to alternative agents rather than simply de-intensifying therapy 1
• Avoid combining medications that increase hypotension risk (diuretics with volume depletion, multiple vasodilators) 1

Non-Pharmacological Approaches First

• Pursue non-pharmacological interventions as first-line treatment for orthostatic hypotension in patients with supine hypertension 1
• Ensure adequate fluid intake and address volume depletion before adjusting antihypertensive regimens 1
• Educate patients to avoid supine dosing of antihypertensives and take last daily dose 3-4 hours before bedtime 6

When Vasopressor Support is Needed

• In patients with clinical evidence of hypotension with hypoperfusion AND elevated cardiac filling pressures (elevated JVP, elevated PCWP), administer IV inotropic or vasopressor drugs to maintain systemic perfusion while pursuing definitive therapy 1
• Midodrine can be considered for orthostatic hypotension but requires caution: avoid in supine hypertension, monitor for bradycardia, use reduced starting dose (2.5 mg) in renal impairment, and avoid concomitant use with MAO inhibitors or drugs that increase BP 6
• Invasive hemodynamic monitoring should guide therapy when adequacy of intracardiac filling pressures cannot be determined clinically 1

Special Populations and Contexts

Older Adults and Frail Patients (≥85 years)

• Maintain BP-lowering treatment lifelong if well tolerated, even beyond age 85 1
• In patients ≥85 years with moderate-to-severe frailty or symptomatic orthostatic hypotension, only consider treatment if BP ≥140/90 mmHg with close tolerance monitoring 1
• Target systolic BP "as low as reasonably achievable" (ALARA principle) when standard targets (120-129 mmHg) are poorly tolerated 1

Heart Failure Patients

• Monitor fluid intake/output, daily weights, vital signs (including standing BP), and daily electrolytes during IV diuretic use 1
• When diuresis causes hypotension with hypoperfusion but elevated filling pressures persist, add inotropic support rather than stopping diuretics 1
• Initiate beta-blockers only after volume optimization and successful discontinuation of IV diuretics, vasodilators, and inotropes, starting at low doses in stable patients 1

Chronic Kidney Disease

• Do not automatically discontinue thiazide diuretics when eGFR decreases to <30 mL/min/1.73 m²—assess individual risks/benefits 1
• Check electrolytes and eGFR within 2-4 weeks of initiating or escalating thiazides 1
• Target systolic BP 120-129 mmHg if eGFR >30 mL/min/1.73 m² and treatment is tolerated; individualize targets for lower eGFR 1

Monitoring and Follow-Up

During Medication Titration

• Use home BP monitoring (HBPM) to avoid hypotension (SBP <110 mmHg) during uptitration to target SBP <130 mmHg 1
• Check basic metabolic panel within 2-4 weeks after adding or titrating medications affecting electrolytes or renal function 1
• Monitor for symptoms of hypotension: fatigue, light-headedness, dizziness, syncope 1, 6
• Follow-up every 6-8 weeks until BP goal safely achieved, then every 3-6 months when stable 1

Patient Education

• Train patients to hold or reduce antihypertensive doses during decreased oral intake, vomiting, or diarrhea to prevent volume depletion and acute kidney injury 1
• Warn about over-the-counter products (cold remedies, diet aids) that can elevate BP and potentiate pressor effects if using midodrine 6

Critical Pitfalls to Avoid

• Never use rapid-acting agents (captopril, immediate-release nifedipine) for asymptomatic hypertensive urgency—no mortality/morbidity benefit and potential harm 2, 3
• Avoid hydralazine, immediate-release nifedipine, and nitroglycerin in hypertensive crises; use sodium nitroprusside cautiously due to toxicity 3, 7
• Do not blame antihypertensive treatment for orthostatic hypotension without first searching for other contributing factors (volume depletion, medications, autonomic dysfunction) 4
• Recognize that hypertension and hypotension frequently coexist, especially in older adults with cardiovascular autonomic dysfunction 5