Postural (orthostatic) hypotension: practical management

1. Urgent assessment: exclude dangerous causes

• Syncope with injury, chest pain, breathlessness, palpitations, new neurological deficit, or active bleeding
• Severe persistent symptoms, inability to stand/walk safely, or shock
• Suspected sepsis, dehydration, GI bleed, arrhythmia, myocardial infarction, or adrenal crisis

• Volume loss: poor intake, vomiting, diarrhea, bleeding, fever
• Drugs: diuretics, nitrates, alpha-blockers, antihypertensives, tricyclics/antipsychotics, opioids, sedatives, dopamine agonists, and drugs for Parkinson disease
• Anaemia, infection, cardiac disease, endocrine disease, diabetic autonomic neuropathy, Parkinsonism or other autonomic failure

2. First-line non-drug measures

• Rise slowly: sit on the side of the bed first, then stand with support. Avoid sudden position change, straining, prolonged standing, and hot showers/environments.
• Hydration: usually 2 to 2.5 L/day if there is no heart failure, advanced kidney disease, or prescribed fluid restriction.
• Salt: increase dietary salt only if safe and clinician-approved. Avoid this strategy in uncontrolled hypertension, heart failure, significant kidney disease, or oedema.
• Water bolus for acute symptoms: drinking about 500 mL water can raise BP within 5 to 10 minutes in many patients with neurogenic orthostatic hypotension.
• Meals: smaller, more frequent meals with lower carbohydrate content if symptoms occur after eating. Avoid alcohol during the day.
• Physical counter-manoeuvres: cross legs, tense buttocks/thighs, calf raises, squat or bend forward when symptoms begin.
• Compression: abdominal binder and/or high-waist compression garments can reduce venous pooling. Knee-length stockings are often less effective.
• Exercise: continue conditioning, preferably seated or recumbent cycling, swimming, or rowing. Avoid abrupt stopping after exercise.
• Head-up sleeping: elevate the head of the bed by about 30 to 45 degrees, particularly if there is supine hypertension.

3. If symptoms persist: prescribed medication

4. Supine hypertension

• Avoid lying flat in daytime.
• Elevate the head of the bed at night.
• Avoid evening doses of midodrine or droxidopa.
• Check home BP lying down and standing. Consider 24-hour ambulatory BP monitoring if there is suspected nocturnal/supine hypertension.
• Night-time antihypertensive treatment should be specialist-led because it can increase nocturnal falls.

5. Monitoring and follow-up

• Record symptoms, falls, fluid intake, and BP/pulse lying and standing.
• Reassess after medication changes, illness, vomiting/diarrhea, or new drugs.
• Check CBC, electrolytes, renal function, glucose, ECG, and targeted endocrine/cardiac tests when clinically indicated.

• Low sodium or potassium
• Dehydration
• Worsening kidney function
• Dizziness, fainting, weakness, cramps, palpitations

1. Contact the clinician who prescribed it today, especially if the symptoms started after beginning it or increasing the dose.
2. Check and record BP and pulse lying down and after standing, if you can do so safely.
3. You may need prompt blood tests: urea/creatinine, sodium, potassium, magnesium, and sometimes bicarbonate.
4. Do not independently stop or change a diuretic if you take it for heart failure, significant oedema, kidney disease, or high blood pressure. The prescriber may advise holding or reducing it, but this needs to be balanced against fluid overload.
5. Seek urgent care now for fainting, confusion, chest pain, breathlessness, very low urine output, severe weakness, persistent vomiting, or a fall/injury.