From the Guidelines
Outpatient evaluation of hypotension should begin with a thorough history and physical examination to identify potential causes, and measure blood pressure in both arms while sitting and standing to assess for orthostatic hypotension, as recommended by the 2020 international society of hypertension global hypertension practice guidelines 1.
Key Components of Evaluation
- Measure blood pressure in both arms, preferably simultaneously, and use the arm with the higher blood pressure if there is a consistent difference between arms 1
- Assess for orthostatic hypotension by measuring standing blood pressure, particularly in patients with symptoms suggesting postural hypotension, the elderly, and people with diabetes 1
- Review the patient's medication list for agents that can cause hypotension, such as antihypertensives, diuretics, antidepressants, and alpha-blockers
- Initial laboratory testing should include complete blood count, comprehensive metabolic panel, thyroid function tests, and morning cortisol level
- An ECG should be performed to evaluate for cardiac causes
Management of Hypotension
- If volume depletion is suspected, provide oral rehydration and consider IV fluids if necessary
- For neurogenic orthostatic hypotension, midodrine (starting at 2.5-5 mg three times daily) or fludrocortisone (0.1 mg daily) may be prescribed, as approved by the FDA for the treatment of orthostatic hypotension 1
- Patients with symptomatic hypotension should be advised to rise slowly from sitting or lying positions, increase salt and fluid intake, wear compression stockings, and avoid alcohol and large meals
- Hypotension requires careful evaluation because it can indicate serious underlying conditions such as adrenal insufficiency, sepsis, or cardiac dysfunction, which may require urgent intervention or referral to specialists depending on the suspected etiology
Additional Considerations
- Physical activity and exercise should be encouraged to avoid deconditioning, which is known to exacerbate orthostatic intolerance, and volume repletion with fluids and salt is critical 1
- Supine blood pressure tends to be much higher in patients with orthostatic hypotension, often requiring treatment of blood pressure at bedtime with shorter-acting drugs that also affect baroreceptor activity 1
From the Research
Outpatient Evaluation of Hypotension
- The evaluation of hypotension in the outpatient setting is crucial to identify underlying pathology and prevent organ injury 2.
- A thorough physical examination, including salient historical features and diagnostic tests, can help guide treatment 2.
- The physical examination is a valuable tool in the outpatient setting, even in the absence of evidence, and can help establish a diagnosis when combined with a thorough history 3.
Diagnostic Approach
- Orthostatic hypotension is a common condition in the elderly, defined as a fall in systolic blood pressure greater than 20 mm Hg or a fall in diastolic blood pressure greater than 10 mm Hg within 3 minutes of standing 4.
- Diagnosis is based on history and a thorough clinical examination, with further testing of the heart, kidneys, and autonomic nervous system may be required in selected patients 4.
- Establishing whether symptoms are due to orthostatic hypotension requires careful history taking, a thorough physical examination, and supine and upright blood pressure measurements 5.
Management
- Non-pharmacological methods, such as slow position change, increased fluid and sodium intake, compression stockings, and elevation of the head of the bed, are key to managing orthostatic hypotension 4.
- Pharmacological treatment with fludrocortisone and midodrine should be tried after non-pharmacological methods, with other drugs used as second-line agents in selected patients 4.
- A stepwise, individualized, and primarily non-pharmacological approach to management is recommended, including cessation of blood pressure-lowering drugs, adoption of lifestyle measures, and treatment with pharmacological agents in selected cases 5.