Evaluation and Management of Orthostatic JEFFREY B. LANIER, MD; MATTHEW B. MOTE, DO; and EMILY C. CLAY, MD Martin Army Community Family Residency, Fort Benning, Georgia

Orthostatic hypotension is defined as a decrease in systolic pressure of 20 mm Hg or a decrease in diastolic of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural changes in blood pressure. may be acute or chronic, as well as symptomatic or asymptomatic. Common symptoms include dizzi- ness, , , weakness, , , , and . Less common symp- toms include , dyspnea, , and neck and shoulder pain. Causes include or blood loss; disorders of the neurologic, cardiovascular, or endocrine systems; and several classes of . Evaluation of suspected orthostatic hypotension begins by identifying reversible causes and underlying associated medical condi- tions. Head-up tilt-table testing can aid in confirming a diagnosis of suspected orthostatic hypotension when standard orthostatic are nondiagnostic; it also can aid in assessing treatment response in patients with an autonomic disorder. Goals of treatment involve improving hypotension without excessive supine , relieving ortho- static symptoms, and improving standing time. Treatment includes correcting reversible causes and discontinuing responsible medications, when possible. Nonpharmacologic treatment should be offered to all patients. For patients who do not respond adequately to nonpharmacologic treatment, , , and are pharmacologic proven to be beneficial. Am( Fam . 2011;84(5):527-536. Copyright © 2011 Ameri- can Academy of Family .) ▲ Patient information: rthostatic hypotension is defined Pathophysiology A handout on orthostatic as a decrease in systolic blood A normal hemodynamic response to hypotension, written by the authors of this article, pressure of 20 mm Hg or a changes in posture requires normal func- is provided on page 537. decrease in diastolic blood pres- tion of the cardiovascular and autonomic O sure of 10 mm Hg within three minutes of nervous systems. Standing results in blood standing compared with blood pressure from pooling of approximately 500 to 1,000 mL the sitting or supine position. Alternatively, in the lower extremities and splanchnic cir- the diagnosis can be made by head-up tilt- culation. This initiates an increase in sym- table testing at an angle of at least 60 degrees.1 pathetic outflow, which increases peripheral Orthostatic hypotension is often found in , venous return, and car- older patients and in those who are frail.2 It diac output, thereby limiting the decrease is present in up to 20 percent of patients older in blood pressure. than 65 years.3 In one study, the prevalence These compensatory mechanisms result of orthostatic hypotension was 18 percent in in a decrease in systolic blood pressure (5 to patients older than 65 years, but only 2 per- 10 mm Hg), an increase in diastolic blood cent of these patients were symptomatic.3 pressure (5 to 10 mm Hg), and an increase in In the absence of volume depletion, rate (10 to 25 beats per minute). How- younger patients with orthostatic hypoten- ever, orthostatic hypotension may result if sion usually have chronic autonomic failure. there is inadequate intravascular volume, A related problem, postprandial hypoten- dysfunction, sion, is common in older patients and those decreased venous return, or inability to with autonomic dysfunction. In postpran- increase in response to pos- dial hypotension, there is a decrease in sys- tural changes.5 Decreased cerebral perfu- tolic blood pressure of at least 20 mm Hg sion produces the neurologic symptoms of within 75 minutes of a meal.4 orthostatic hypotension.5

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence Clinical recommendation rating References

Consider head-up tilt-table testing in patients with symptoms of C 6, 14 orthostatic hypotension despite normal vital signs, or in patients who are unable to stand for orthostatic vital sign measurements. Patients with chronic orthostatic hypotension should be counseled C 6, 22 to avoid large carbohydrate-rich meals, limit alcohol intake, and ensure adequate hydration. Fludrocortisone, midodrine, and pyridostigmine (Mestinon) are B 26, 28, 29 effective therapies for chronic orthostatic hypotension.

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

Clinical Presentation and Evaluation may present with neck and shoulder pain, Orthostatic hypotension may be acute or orthostatic dyspnea, and chest pain.7 Table 1 chronic. Patients may present with light- outlines the of ortho- headedness, blurred vision, , weak- static hypotension, which may be caused by ness, and fatigue, or with syncope (in the a number of things, including dehydration, setting).6 Less commonly, they blood loss, , or a disorder of the neurologic, cardiovascular, or endocrine sys- tem.8-10 Evaluation of suspected orthostatic Table 1. Differential Diagnosis of Orthostatic Hypotension hypotension begins by identifying reversible causes and underlying associated medical Cardiovascular 8-10 Endocrine10 conditions. Table 2 lists historical features that suggest a specific diagnosis in the Cardiac insipidus patient with orthostatic hypotension.7,8 In Congestive failure Hyperglycemia, acute addition to assessing for symptoms of ortho- Myocardial