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Orthostatic hypotension

Key sources
The following summarized guidelines for the evaluation and management of orthostatic hypotension are prepared by our editorial team based on guidelines from the International Liaison Committee on Resuscitation (ILCOR 2019), the American Heart Association (AHA/HRS/ACC 2017), and the European Federation of Neurological Societies (EFNS 2006).
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Guidelines

1.Diagnostic investigations

Initial evaluation
Obtain the following as part of the initial evaluation of patients with suspected OH:
structured history taking
detailed physical examination
supine and upright BP measurements
12-lead ECG recording
active standing or head-up tilt, ideally with continuous assessment of BP and HR for 3 min
B
Obtain further autonomic nervous system screening tests, with other appropriate investigations, depending on the possible etiology of the underlying disorder.
B
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2.Medical management

Fludrocortisone
Administer fludrocortisone as first line drug-monotherapy of OH.
B
Advise patients to maintain a high dietary salt and adequate fluid intake to obtain full benefits from fludrocortisone treatment.
B

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3.Nonpharmacologic interventions

Physical and nutritional measures
Physical measures that may improve OH include leg crossing, squatting, elastic abdominal binders and stockings, and careful exercise.
E
Increased water (2-2.5 L/day) and salt ingestion (> 8 g or 150 mmol/day) effectively improve OH.
E

4.Therapeutic procedures

Physical counterpressure maneuvers
Advise the use of any type of physical counterpressure maneuvers by individuals with acute symptoms of presyncope from vasovagal or orthostatic causes in the first aid setting.
B
Recognize that we suggest that lower-body physical counterpressure maneuvers such as leg crossing and tensing or squatting are preferable to upper-body and abdominal physical counterpressure maneuvers.
B

5.Specific circumstances

Patients with syncope: advise acute water ingestion in patients with syncope caused by neurogenic OH for occasional, temporary relief.
B
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6.Patient education

Physical and nutritional measures: counsel patients on the various factors that influence BP, and specific elements that must be avoided (foods, habits, positions and drugs).
E