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Orthostatic Hypotension: Causes and Treatment

Orthostatic hypotension is a sudden drop in blood pressure upon standing that can cause dizziness or fainting. Learn about its causes, symptoms, and treatment.

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Things worth knowing about "Orthostatic Hypotension"

Orthostatic hypotension is a sudden drop in blood pressure upon standing that can cause dizziness or fainting. Learn about its causes, symptoms, and treatment.

What is Orthostatic Hypotension?

Orthostatic hypotension (also called postural hypotension) is a sudden drop in blood pressure that occurs when a person moves from a lying or sitting position to an upright posture. It is medically defined as a decrease in systolic blood pressure (the upper reading) of at least 20 mmHg or a decrease in diastolic blood pressure (the lower reading) of at least 10 mmHg within three minutes of standing. The condition may occur occasionally or serve as a sign of an underlying medical disorder.

Causes

Orthostatic hypotension can have many different causes. Most commonly, there is a dysfunction of the autonomic nervous system, which normally regulates blood pressure when a person stands up. Additional causes include:

Dehydration: Low fluid intake reduces blood volume and impairs the body's compensatory mechanisms.
Medications: Antihypertensives, diuretics, antidepressants, and certain Parkinson's medications can contribute to orthostatic hypotension.
Heart conditions: Heart failure, arrhythmias, or heart valve disorders can impair the heart's pumping capacity.
Neurological disorders: Parkinson's disease, multiple system atrophy, or diabetic neuropathy affect nerve signals that regulate blood pressure.
Endocrine disorders: Addison's disease or hypothyroidism can reduce blood pressure regulation.
Prolonged bed rest or immobility: Common after hospitalisation or periods of limited activity.
Alcohol and heat exposure: Both cause vasodilation, which can lower blood pressure significantly.

Symptoms

Symptoms of orthostatic hypotension typically appear shortly after standing and usually last only a few seconds to minutes. They include:

Dizziness or lightheadedness
Blurred vision or brief visual blackout
Fainting or loss of consciousness (syncope)
Weakness or heaviness in the legs
Headache, particularly at the back of the head
Rapid heartbeat or palpitations
Nausea

In older adults, orthostatic hypotension is a significant risk factor for falls and related injuries, making it a serious clinical concern in geriatric care.

Diagnosis

Diagnosis is primarily established by measuring blood pressure in different body positions:

Active standing test (Schellong test): Blood pressure and heart rate are measured while lying down and then repeatedly after standing up.
Tilt-table test: The patient is secured to a table that gradually tilts from horizontal to vertical, allowing monitoring of cardiovascular responses.
24-hour ambulatory blood pressure monitoring (ABPM): Records blood pressure fluctuations throughout the day and night.
Laboratory tests: Blood counts, electrolytes, and hormone levels help identify underlying conditions.

The patient's medical history and a full list of current medications are also carefully reviewed.

Treatment

General Measures

In many cases, lifestyle modifications alone can significantly improve orthostatic hypotension:

Rising slowly from a lying or seated position
Adequate fluid intake (approximately 2 to 2.5 litres per day)
Increased salt intake (only under medical supervision)
Wearing compression stockings to improve venous return from the legs
Avoiding alcohol, prolonged hot baths, and excessive heat
Regular physical exercise, particularly exercises that strengthen the leg muscles
Sleeping with the head of the bed slightly elevated

Medical Treatment

When lifestyle changes are insufficient, medications may be prescribed:

Fludrocortisone: A mineralocorticoid that promotes sodium retention and increases blood volume.
Midodrine: An alpha-1 adrenergic agonist that constricts blood vessels and raises blood pressure.
Droxidopa: Used particularly in patients with Parkinson's disease-related orthostatic hypotension.

Treatment is always guided by the underlying cause and should be individually tailored in consultation with a healthcare provider. If the condition is medication-induced, adjusting or switching the causative drug may provide relief.

References

Freeman R. et al. - Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Autonomic Neuroscience, 2011.
Lahrmann H. et al. - Orthostatic Hypotension. Wiener Medizinische Wochenschrift, 2006.
Kaufmann H. - Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Clinical Autonomic Research, 1996.

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