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Classification

Clinical definition Pathophysiology
BP fall Time line for symptoms after standing Symptoms Resolving
Initial orthostatic hypotension (iOH)
  • Transient BP decrease of >40 mmHg systolic or >20 mmHg diastolic
  • 5-15 s after standing
  • Yes
  • Symptoms resolve by 20s
  • Healthy adolescents
  • More pronounced during active standing leading to venous pooling
Neurogenic orthostatic hypotension (nOH)
  • Sustained BP decrease of >20 mmHg systolic or >10 mmHg diastolic
  • Within 3 mins
  • With or without
  • Impaired noradrenergic responses to the Valsalva maneuver.
  • Failure of noradrenergic nerves to maintain BP in response to standing.
Delayed orthostatic hypotension (dOH)
  • Sustained BP decrease of >20 mmHg systolic or >10 mmHg diastolic
  • After 3 mins
  • Yes
  • Similar to nOH
  • Early or milder form of nOH
Neurally mediated syncope (vOH)
  • BP declines over 1–3 min.
  • After 7s when BP falls below 50mm
  • Yes
  • Paroxysmal withdrawal of sympathetic vasopressor tone, often during prolonged standing
Cardiovascular orthostatic hypotension (cOH)



Non-Pharmacological methods Mechanism of alleviating hypotension Recommendations
Elastic stockings
  • Reduce venous pooling in the splanchnic and mesenteric circulations.
  • Elastic stockings expanding up to the waist are recommended.
  • Leg compression alone is not considered effective.
    • Due to the minor venous capacitance of legs relative to the abdomen.
  • Separate abdominal and leg compression is recommended to avoid patient's discomfort.
Physical Maneuvers
  • Transiently increase venous return and peripheral vascular resistance
  • Contraction of a group of muscles
  • Leg-crossing
  • Toe raising
  • Bending at the waist
Head up tilt sleeping
  • Enhance orthostatic tolerance upon the first-morning rise
  • Results in reduction in supine hypertension, pressure-natriuresis
Intravascular volume
  • Tubular loss of salt and fluid
  • Decreased vascular tone creates relative hypovolemia
  • Volume expansion can alleviate symptoms even in the presence of normal intravascular volume.
    • 2 liters of water and 6 g of salt
    • Twenty-four-hour urine collection is helpful to guide treatment and follow-up
Intake of cold water
  • Increase systolic orthostatic hypotension by more than 30 mmHg
    • Via gastropressor response
  • Rapid drinking of approximatively 500 mL of cold water, independent of daily water intake


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Drop of systolic BP > 20 mmHg (30 for hypertensive patients)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Symptomatic
 
 
 
 
 
 
 
 
 
 
 
Asymptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-pharmacological treatment
 
 
 
 
 
 
 
 
 
 
 
Observation and follow-up
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Persistance of symtoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pharmacological Treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No supine hypertension or chronic heart failure
 
 
 
 
 
 
 
 
 
 
 
Supine hypertension or chronic heart failure:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fludrocortisone
Midodrine
 
 
 
 
 
 
 
 
 
 
 
Midodrine
 


Stepwise approach


 
 
 
 
 
 
 
 
Steps to approach a patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
When we should suspect orthostatic hypotension?
Unexplained fall/syncope
Typical symptoms
Patient history
Current pharmacological treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial assessment (outpatient clinic. ED and hospital):
Physical examination

Laboratory assessment
Bedside BP supine/standing test (after 1-3.5 min)
Cardiac assessment

Neurological assessment
 
 
 
 
 

Initial Therapy

  • Preferred regimen (1): Fludrocortisone acetate at a dose of 0.1 mg per day, administered in the morning, which can eventually be increased up to 0.3 mg per day.
  • Preferred regimen (2): Midodrine 2.5 to 10 mg three times a day.
    • Max dose should not exceed 40 mg/day.
  • Preferred regimen (2): Droxidopa starts at 100 mg and escalates to 600 mg three times per day.
    • Patients should not take droxidopa within four to five hours of bedtime in order to limit supine hypertension.

Secondline Therapy

  • Preferred regimen (1): Erythropoietin is administered SC or IV at doses between 25 to 75 units/kg three times a week.
  • Preferred regimen (1): Methylxanthine caffeine 100 to 250 mg three times a day with meals.
  • Preferred regimen (1): Pyridostigmine initiated at a dose of 30 mg three times daily, up to a maximum dose of 90 mg three times daily.
  • Preferred regimen (1): Nonsteroidal anti-inflammatory drugs are rarely effective as monotherapy
    • They can supplement treatment with fludrocortisone or a sympathomimetic agent.

Thirdline Therpay

  • Preferred regimen (1): Atomoxetine
  • Preferred regimen (1): Vasopressin analogs (desmopressin (DDAVP))
  • Preferred regimen (1): Yohimbine a single dose of yohimbine (5.4 mg).
    • Yohimbine has limited availability in the United States.
  • Preferred regimen (1): Somatostatin subcutaneous doses range from 25 to 200 mcg.
  • Preferred regimen (1): Ergotamine-caffeine (1 mg/100 mg) up to twice-daily dosing in patients with orthostatic hypotension.
  • Preferred regimen (1): Metoclopramide and domperidone

Supine Hypertension