Orthostatic Hypotension

At a glance

Symptoms: Lightheadedness, blurred vision, or fainting on standing up
Common causes: Dehydration, medications, autonomic nerve damage, Parkinson's disease
How it's diagnosed: Lying and standing blood pressure checks and tilt table testing
Treatment: Fluids and salt, a medication review, compression, and medication if needed

Overview

Orthostatic hypotension represents a significant drop in blood pressure upon standing, often observed in elderly patients. It's clinically marked by a decrease in systolic blood pressure by at least 20mm Hg or diastolic blood pressure by 10mm Hg within three minutes of standing. This condition highlights a failure in the body's complex regulatory system to compensate for gravity-induced blood pressure reductions.

Symptoms

Lightheadedness
Disequilibrium
Blurred vision or “browning-out”
Weakness
Fatigue
Cognitive impairment
Syncope (fainting)

Improvement is typically seen when returning to sitting, lying down, or standing with support.

Causes and risk factors

Orthostatic hypotension can stem from neurogenic and non-neurogenic origins:

Neurogenic causes

Peripheral neuropathy (e.g., diabetes, autoimmune diseases)
Parkinson’s disease
Multiple system atrophy
Pure autonomic failure
Lewy body dementia
Multiple sclerosis
Postural orthostatic tachycardia syndrome (POTS)

Non-neurogenic causes

Cardiac impairment (e.g., myocardial infarction, aortic stenosis)
Dehydration
Adrenal insufficiency
Vasodilation (e.g., fever)
Medications like diuretics, alpha-blockers for BPH, antihypertensives, and calcium channel blockers

Diagnosis

Diagnosis involves a tilt test or a tilt table test, monitoring blood pressure and heart rhythm from lying to standing positions, identifying significant changes that confirm orthostatic hypotension.

Treatment

Management aims at elevating standing blood pressure without adversely affecting supine blood pressure, focusing on reducing symptoms and improving daily activity tolerance. Strategies include:

Abdominal compression and compression stockings
Boluses of water for rapid symptom relief
Bed elevation to mitigate morning symptoms
Countermaneuvers like leg crossing and thigh muscle contraction
Medication adjustments, considering fludrocortisone and midodrine
Education on symptom triggers and management
Exercise, favoring mild, recumbent activities
Fluid and salt intake adjustments for optimal plasma volume

Testing that can help

Testing is chosen from your history and examination. These are the tests most often used here.

Tilt Table TestingTracks blood pressure and heart rate as the body is tilted upright, to evaluate lightheadedness and fainting.

Specialty care: Orthostatic HypotensionOrthostatic hypotension represents a significant drop in blood pressure upon standing, often observed in elderly patients.Cardiac ArrhythmiasAn arrhythmia is a heartbeat that is irregular, too fast, or too slow. When the heart pumps less effectively, it can cause lightheadedness, palpitations, or fainting.Parkinson's DiseaseParkinson's disease is a progressive movement disorder that causes tremor, slowness, stiffness, and balance problems, and it can also affect blood pressure control.DizzinessDizziness can mean spinning (vertigo), lightheadedness, or unsteadiness, and each points toward different causes.

When to seek urgent care

Call 911 or go to the nearest emergency department if dizziness or imbalance starts suddenly together with any of the following, since these can be signs of a stroke or another emergency:

Weakness or numbness of the face, arm, or leg, especially on one side
Trouble speaking or understanding speech
Double vision or sudden loss of vision
A sudden, severe headache
Inability to walk or stand
Chest pain, fainting, or a seizure