Should antihypertensive therapy be held in an elderly, symptomatic patient who has a positive orthostatic blood pressure test (≥20 mm Hg systolic or ≥10 mm Hg diastolic drop on standing)?

Management of Antihypertensive Therapy in Patients with Orthostatic Hypotension

Do not routinely discontinue all blood pressure medications when orthostatic hypotension is detected; instead, switch medications that worsen orthostatic hypotension to alternative antihypertensive agents that are better tolerated, rather than simply de-intensifying therapy. 1

Primary Management Strategy

The 2024 European Society of Cardiology guidelines provide the most current and definitive guidance: for patients with supine hypertension and orthostatic hypotension, pursue non-pharmacological approaches as first-line treatment and switch BP-lowering medications that worsen orthostatic hypotension to alternative BP-lowering therapy—do not simply de-intensify therapy. 1 This represents a paradigm shift from older approaches that focused on medication withdrawal.

Key Principle: Medication Switching vs. Withdrawal

• The goal is to maintain blood pressure control while minimizing orthostatic symptoms, not to abandon hypertension treatment entirely 1
• This approach recognizes that untreated hypertension carries significant cardiovascular morbidity and mortality risk that often outweighs the risks of orthostatic hypotension 1

Medications Most Likely to Cause Orthostatic Hypotension

When evaluating which medications to switch, prioritize removal or substitution of these high-risk agents:

• Alpha-1 blockers (e.g., doxazosin, prazosin, terazosin) are among the most common culprits and should be discontinued first 2
• Centrally acting agents (e.g., clonidine, methyldopa) frequently cause orthostatic hypotension 2
• Non-selective adrenergic blockers carry higher risk than selective beta-blockers 2
• Potassium-sparing diuretics show strong association with orthostatic hypotension in geriatric populations 3
• Beta-blockers are associated with orthostatic hypotension, particularly in elderly patients (56% of those with OH vs. 32% without) 3
• Calcium channel blockers are frequently discontinued when orthostatic hypotension is identified 3

Preferred Alternative Antihypertensive Agents

When switching medications, consider these better-tolerated options:

• ACE inhibitors and ARBs (RAS blockers) have lower rates of orthostatic hypotension compared to other classes 1
• Thiazide diuretics at appropriate doses are generally well-tolerated, though excessive diuresis can precipitate orthostatic hypotension 2
• Dihydropyridine calcium channel blockers may be better tolerated than non-dihydropyridines 1

Clinical Algorithm for Management

Step 1: Confirm Diagnosis and Assess Severity

• Measure BP after 5 minutes supine/sitting, then at 1 and 3 minutes after standing 1, 4
• Orthostatic hypotension is defined as ≥20 mmHg systolic or ≥10 mmHg diastolic drop within 3 minutes 1, 4
• Critical pitfall: In patients with supine hypertension, use a threshold of ≥30 mmHg systolic drop 4
• Assess for symptoms: dizziness, lightheadedness, syncope, falls 5

Step 2: Identify Reversible Causes Before Adjusting Antihypertensives

• Review all medications, not just antihypertensives—psychotropic drugs, sedatives, and dopamine agonists commonly cause orthostatic hypotension 2
• Assess for volume depletion, anemia, or endocrine disorders 6
• Evaluate for autonomic dysfunction (neurogenic vs. non-neurogenic based on heart rate response) 4

Step 3: Implement Non-Pharmacological Interventions First

• Increase fluid intake to 2-2.5 liters daily 6
• Liberalize salt intake to 8-10 grams daily (unless contraindicated by heart failure) 6
• Elevate head of bed by 10 degrees to reduce nocturnal diuresis 6
• Teach physical counterpressure maneuvers (leg crossing, squatting, arm tensing) 6

Step 4: Medication Adjustment Strategy

For symptomatic patients:

• Identify and switch (not discontinue) the most likely offending antihypertensive agent 1
• Replace with an alternative class that maintains BP control but has lower orthostatic risk 1
• Monitor standing BP at follow-up visits to ensure orthostatic hypotension improves 1

For asymptomatic patients:

• Do not ignore asymptomatic orthostatic hypotension—it carries a 64% increase in age-adjusted mortality and increased fall risk 1, 6
• Still consider medication switching if orthostatic drop is significant (≥30 mmHg systolic) 4
• The presence of orthostatic hypotension without symptoms does not eliminate cardiovascular risk 7

Step 5: Special Considerations for Elderly Patients

• Caution with dual-drug initiation: When starting antihypertensive therapy in older patients, carefully monitor for orthostatic hypotension if initiating two drugs simultaneously 1
• Use slow titration approach in patients with history of orthostatic symptoms 1
• The misperception of "brittle hypertension" in elderly patients has led to widespread undertreatment—most elderly patients can achieve BP control with appropriate medication selection 1
• Maintain lifelong BP-lowering treatment even beyond age 85 if well tolerated 1

Evidence Supporting Medication Switching Over Withdrawal

• A study of elderly hypertensive patients showed that withdrawal of antihypertensive therapy reduced orthostatic hypotension prevalence from 23% to 11% over 12 months, but this approach leaves hypertension untreated 8
• More recent evidence demonstrates that screening for orthostatic hypotension leads to selective de-prescribing (17% medication discontinuation in OH-positive vs. 4% in OH-negative patients), not blanket withdrawal 3
• The 2024 ESC guidelines explicitly recommend switching rather than de-intensifying, reflecting current best practice 1

Common Pitfalls to Avoid

• Pitfall #1: Discontinuing all antihypertensives when orthostatic hypotension is detected, leaving hypertension untreated 1
• Pitfall #2: Failing to measure standing BP routinely in elderly patients—orthostatic hypotension affects up to 50% of institutionalized elderly 4
• Pitfall #3: Measuring BP only immediately after standing, which misses classical orthostatic hypotension that develops over 1-3 minutes 4
• Pitfall #4: Ignoring asymptomatic orthostatic hypotension, which still carries significant mortality risk 1, 7
• Pitfall #5: Failing to monitor for supine hypertension when treating orthostatic hypotension—the goal is to improve standing BP without excessive supine hypertension 6
• Pitfall #6: Not extending standing time beyond 3 minutes in symptomatic patients with negative initial testing—delayed orthostatic hypotension occurs in 15% of cases between 3-10 minutes 4

Monitoring Strategy

• Recheck orthostatic vital signs at 1,3, and 6 months after medication adjustment 8
• Measure BP in both arms initially; use the arm with higher readings if difference >10 mmHg 4, 6
• Consider 24-hour ambulatory BP monitoring to detect patterns of BP variability and supine hypertension 6
• Obtain ECG to rule out arrhythmias contributing to symptoms 6