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This is a corrected version of the article that appeared in print.

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

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

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

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 measuring blood pressure and heart rate after five minutes in the supine position and three minutes after moving to a standing position. [corrected] 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.

Clinical recommendation Evidence rating Comments
The test for the diagnosis of orthostatic hypotension should consist of blood pressure and heart rate measurement in the supine position for five minutes followed by standing position for three minutes, instead of sitting to standing position.24,2628 [corrected] 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

With increasing age, there is a normal decline in baroreceptor sensitivity and increase in autonomic neurodegenerative disease.2 Orthostatic hypotension occurs in only 5% of middle-aged adults but affects approximately 20% of those 60 years and older.35 Prevalence in nursing homes and geriatric wards is as high as 50% and 68%, respectively.1,6

Orthostatic hypotension is associated with significant morbidity and mortality, with the greatest risk in those who have comorbidities. Several large meta-analyses reported that orthostatic hypotension is associated with up to a 50% increase in relative risk of all-cause mortality (relative risk [RR] = 1.50; 95% CI, 1.24 to 1.81).79 In middle-aged, community-dwelling patients, it is associated with an increased risk of death (hazard ratio = 1.19 [95% CI, 1.09 to 1.30] to 1.70 [95% CI, 1.40 to 2.00]) after adjustment for other risk factors.10,11

Orthostatic hypotension is also associated with increased rates of coronary heart disease, myocardial infarction, heart failure, stroke, and falls.3,810 Older people especially are at risk of myocardial infarction and recurrent falls.12,13 Patients with diabetes mellitus are more likely to develop orthostatic hypotension and have an increased risk of mortality, microvascular and macrovascular complications, and cardiovascular events.1418 In the United States, the rate of hospitalizations related to orthostatic hypotension is 36 per 100,000 adults and increases to 233 per 100,000 adults for those 75 years and older.19

Pathophysiology

Approximately 500 to 1,000 mL of blood pools in the splanchnic circulation and lower extremities when a person stands, causing a decrease in venous return and cardiac output.2,2022 Baroreceptors detect decreased stretch and activate the sympathetic nervous system, which elevates the heart rate, bolsters contractility, and increases peripheral resistance through vasoconstriction.2,21 Baroreceptors also sense decreased blood volume, prompting upregulation of renin release, sodium reabsorption, and vasopressin activity, resulting in enhanced water retention.2,21 Orthostatic hypotension occurs when there is inadequate intravascular volume or when sympathetic nervous system–mediated vasoconstriction is unable to compensate for gravitational pooling, leading to decreased organ perfusion and associated symptoms 20,23 (Figure 1).

Clinical Presentation and Evaluation

Symptoms of orthostatic hypotension appear while assuming a standing or upright position and are relieved by returning to a supine position (Table 1).2,22,24 These symptoms are due to organ hypoperfusion compensation, but they do not have to be present for a diagnosis.2,5 A history and physical examination aimed at identifying underlying causes of orthostatic hypotension should be performed. Risk factors for orthostatic hypertension are outlined in Table 2.19,24,25

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