In a 39‑year‑old woman with hypermobile Ehlers‑Danlos syndrome and suspected postural orthostatic tachycardia syndrome who records home blood pressures three times daily averaging 106/71–126/86 mm Hg, does this affect the need for antihypertensive treatment or alter the management plan?

Home Blood Pressure Monitoring Does Not Change Management in This Patient

These home blood pressure readings (106/71–126/86 mm Hg) confirm that antihypertensive medication is not indicated and should not be initiated. This patient's readings fall well below the treatment threshold for hypertension and actually raise concern for potential orthostatic hypotension given her underlying conditions.

Blood Pressure Classification and Treatment Thresholds

Your patient's home BP readings place her in the non-elevated to elevated BP category, not hypertension:

• Non-elevated BP: <120/70 mm Hg 1
• Elevated BP: 120–139/70–89 mm Hg 1
• Hypertension: ≥140/90 mm Hg 1

Her readings of 106/71–126/86 mm Hg span from non-elevated to the lower range of elevated BP. Antihypertensive medication is only recommended when confirmed BP is ≥140/90 mm Hg 1.

Critical Considerations in Ehlers-Danlos Syndrome with POTS

Orthostatic Hypotension Risk

Patients with hypermobile EDS and POTS commonly experience orthostatic intolerance and may have baseline low blood pressure 2, 3. Key concerns include:

• Dysautonomia in EDS/POTS causes orthostatic intolerance with symptoms relieved by sitting or lying, exacerbated by vasodilatation from food, exertion, and heat 2
• POTS is defined by heart rate increase >30 bpm in adults when upright WITHOUT a fall in blood pressure 2
• Some patients have POTS compounded by the presence of low BP 2
• Autonomic dysfunction associated with hEDS is the proposed mechanism underlying both POTS and related symptoms 3

Medication Contraindications

Antihypertensive medications would be particularly harmful in this patient:

• Ivabradine is recommended for symptomatic patients with POTS, not antihypertensives 1
• Beta-blockers are recommended for management of POTS when indicated 1
• Diuretics, vasodilators, and alpha-blockers are common culprits causing orthostatic hypotension in susceptible patients 4
• ACE inhibitors and calcium antagonists have more pronounced hypotensive effects in patients with autonomic dysfunction 4

Proper Management Strategy

Confirm Orthostatic Vital Signs

Measure orthostatic BP to assess for orthostatic hypotension before any treatment decisions:

• Measure BP after 5 minutes supine rest, then at 1 and 3 minutes after standing 5, 4
• Orthostatic hypotension is defined as ≥20 mm Hg systolic OR ≥10 mm Hg diastolic drop within 3 minutes 5, 4
• This is especially important in patients with EDS/POTS who commonly have autonomic dysfunction 2, 3

Lifestyle Measures Only

For BP in the 120–139/70–89 mm Hg range without high-risk conditions, lifestyle measures are recommended 1:

• No pharmacological BP-lowering treatment is indicated 1
• Focus on lifestyle modifications for cardiovascular health 1
• Reassess BP in 3–6 months 1

Address POTS-Specific Management

If POTS symptoms are problematic, consider POTS-specific therapies rather than antihypertensives:

• Ivabradine alone or with beta-blockers for symptomatic inappropriate sinus tachycardia and POTS 1
• Increased fluid and salt intake to expand plasma volume 2
• Compression garments to reduce venous pooling 2
• Gradual exercise reconditioning programs 6

Common Pitfalls to Avoid

Do not initiate antihypertensive therapy based on:

• Isolated office readings without out-of-office confirmation 1
• BP readings that fall below the hypertension threshold of 140/90 mm Hg 1
• Concern about "borderline" readings in a patient with conditions predisposing to low BP 2

Do not overlook:

• The need for orthostatic vital sign assessment in patients with EDS/POTS 5, 4, 2
• That patients with POTS+hEDS have greater healthcare utilization and chronic pain, requiring comprehensive symptom management rather than BP lowering 7
• That symptoms of orthostatic intolerance may worsen with antihypertensive medications 4, 2