ASH position paper: evaluation and treatment of orthostatic hypotension

Abstract

This paper provides recommendations on the treatment of orthostatic hypotension (OH) as reviewed by the American Society of Hypertension. It focuses on recent reports on the evaluation and management of OH and provides practical advice for clinicians on how to screen, diagnose, and treat patients using behavioral, nonpharmacologic, and pharmacologic strategies. The authors also provide a stepwise approach on how to apply new findings to successfully control OH and reduce the risk of syncope and falls in these patients. Treatment of OH is also discussed in special situations such as in hypertensive and hospitalized patients. It should be noted, however, that research in this area is mostly limited to studies in small numbers of patients. Unfortunately, the trials of the type needed to develop evidence-based guidelines are not available for this condition.

Figure 1

Left panel shows the normal response to upright posture. Patients with orthostatic hypotension (OH) are unable to compensate for the posture‐induced changes in venous return to the heart. The right panel shows a continuous blood pressure (BP) tracing of a patient with neurogenic OH (lower tracing) in a transition from supine to upright posture. Note the profound decrease in BP without an adequate compensatory increase in heart rate (upper tracing). Note also the presence of supine hypertension, a condition often seen in patients with OH. CNS indicates central nervous system, CV, cardiovascular; bpm, beats per minute; HR, heart rate.

Figure 2

Approach to the evaluation and treatment of orthostatic hypotension. SBP indicates systolic blood pressure; DBP, diastolic blood pressure; HTN, hypertension; CHF, congestive heart failure, PRN, as needed.