Updated: 12/6/2021

Orthostatic Hypotension

Review Topic
  • Snapshot
    • A 66-year-old man presents to his primary care physician for generalized weakness and episodes of lightheadedness. He says that his symptoms began approximately a few weeks ago after there was a change in his blood pressure medications. Medical history is significant for hypertension and newly diagnosed benign prostatic hyperplasia. After being in the supine position for 5 minutes, he was asked to stand, and a blood pressure was obtained 3 minutes after standing. There was a 23 mmHg decrease in systolic blood pressure.
  • Introduction
    • Clinical definition
      • a decrease in blood pressure while the patient is standing compared to when they are sitting or in a supine position
        • ≥ 20 mmHg decrease in systolic blood pressure OR
        • ≥ 10 mmHg decrease in diastolic blood pressure
  • Epidemiology
    • Incidence
      • commonly seen in the elderly
        • likely secondary to impaired baroreceptor sensitivity
    • Risk factors
      • antihypertensive medications
      • diuretics
      • volume depletion (e.g., vomiting and hemorrhage)
  • Etiology
    • Autonomic failure
    • Volume depletion/dehydration
      • most common cause in the elderly
        • while not necessary for diagnosis, may show decreased FENa (<1%)
    • Medications (e.g., terazosin) 
    • Pathophysiology
      • physiology
        • gravitational pooling of blood decreases venous return, cardiac output, and blood pressure
        • compensatory mechanisms regulate blood pressure by controlling
          • vasoconstriction
          • heart rate
          • cardiac contractility
      • pathogenesis
        • failure of compensatory mechanisms to regulate blood pressure when the patient is in the upright position
          • e.g., autonomic failure
  • Presentation
    • Symptoms
      • dizziness
      • lightheadedness
      • vision changes (e.g., vision blurring or darkening)
      • generalized weakness
  • Studies
    • Blood pressure measurements
      • obtain blood pressure measurements 2-5 minutes after the patient is standing from a supine position
        • it is diagnosed if there is
          • ≥ 20 mmHg decrease in systolic blood pressure OR
          • ≥ 10 mmHg decrease in diastolic blood pressure
    • Electrocardiogram
      • performed to rule-out cardiac arrhythmia
  • Treatment
    • Conservative
      • treat the underlying cause
        • e.g., medication alterations
      • dietary modification
        • in the absence of hypertension, the patient should increase fluid and salt intake
    • Medical
      • midodrine or fludrocortisone
        • indication
          • indicated in patients who do not respond to conservative treatment
  • Complications
    • There is an increased cardiovascular and all-cause mortality
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