Orthostatic Hypotension: A Practical Approach

 

Am Fam Physician. 2022 Jan ;105(1):39-49.

  Patient information: See related handout on orthostatic hypotension, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Orthostatic hypotension is defined as a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the supine position or on assuming a head-up position of at least 60 degrees during tilt table testing. Symptoms are due to inadequate physiologic compensation and organ hypoperfusion and include headache, lightheadedness, shoulder and neck pain (coat hanger syndrome), visual disturbances, dyspnea, and chest pain. Prevalence of orthostatic hypotension in the community setting is 20% in older adults and 5% in middle-aged adults. Risk factors such as diabetes mellitus increase the prevalence of orthostatic hypotension in all age groups. Orthostatic hypotension is associated with a significant increase in cardiovascular risk and falls, and up to a 50% increase in relative risk of all-cause mortality. Diagnosis is confirmed by performing a bedside simplified Schellong test, which consists of blood pressure and heart rate measurements after five minutes in the supine position and three minutes after moving to a standing position. If the patient is unable to stand safely or the clinical suspicion for orthostatic hypotension is high despite normal findings on the bedside test, head-up tilt table testing is recommended. Orthostatic hypotension is classified as neurogenic or nonneurogenic, depending on etiology and heart rate response. Treatment goals for orthostatic hypotension are reducing symptoms and improving quality of life. Initial treatment focuses on the underlying cause and adjusting potentially causative medications. Nonpharmacologic strategies include dietary modifications, compression garments, physical maneuvers, and avoiding environments that exacerbate symptoms. First-line medications include midodrine and droxidopa. Although fludrocortisone improves symptoms, it has concerning long-term effects.

Orthostatic hypotension is defined as a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the supine position or on assuming a head-up position of 60 degrees during tilt table testing.1 It is classified as neurogenic or nonneurogenic based on etiology and heart rate response.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

The bedside simplified Schellong test for the diagnosis of orthostatic hypotension should consist of supine position for five minutes followed by standing position for three minutes, instead of sitting to standing position.24,2628

C

Expert opinion, consensus guidelines, and a single retrospective study

If clinical suspicion for orthostatic hypotension is high, head-up tilt table testing should be performed even with normal bedside orthostatic vital signs.24,28,33,43,44

C

Expert opinion and consensus guidelines; three small cohort studies of older patients showing low sensitivity of bedside orthostatic vital signs compared with tilt table testing

Patients with neurogenic orthostatic hypotension and supine hypertension should be evaluated with a 24-hour ambulatory blood pressure monitor.45

C

Expert opinion and consensus guidelines in the absence of clinical trials

Treatment of orthostatic hypotension should be aimed at reducing symptoms to improve quality of life, rather than normalizing blood pressure.2,22,24,46

C

Expert opinion and consensus guidelines in the absence of clinical trials with head-to-head comparisons of blood pressure vs. symptom control

Nonpharmacologic management strategies should be attempted before prescribing a medication. If nonpharmacologic management is insufficient alone, it should be used in combination with medications.2,22,24,33,66

C

Expert opinion and consensus guidelines

First-line pharmacologic therapy should include midodrine or droxidopa (Northera) titrated to relieve symptoms.2,22,24,5661,66

B

Consensus guidelines; four small double-blind randomized controlled trials showing improved blood pressure and global symptom scores compared with placebo


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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MICHAEL J. KIM, MD, FAAFP, is a faculty member at the David Grant Medical Center, Travis Air Force Base (Calif.) Family Medicine Residency Program, and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md. At the time this article was written, he was a faculty member at the Saint Louis University, Southwest Illinois Family Medicine Residency Program, O'Fallon....

JENNIFER FARRELL, DO, is a faculty member at the Saint Louis University Southwest, Illinois Family Medicine Residency Program; an assistant professor in the Department of Family Medicine at Saint Louis University School of Medicine; and a staff physician at Health Sisters Hospital System, St. Elizabeth Hospital, O'Fallon.

Address correspondence to Michael J. Kim, MD, FAAFP, 60 HCOS/SGGF, 101 Bodin Circle, Travis AFB, CA 94535 (email: drmichaeljkim@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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