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Orthostatic hypotension

Last reviewed: 10 Apr 2025
Last updated: 13 Dec 2024

Summary

Definition

History and exam

Key diagnostic factors

  • older adult age
  • use of high-risk medications
  • underlying medical condition
  • postural lightheadedness, syncope, and other symptoms of cerebral hypoperfusion
Full details

Other diagnostic factors

  • parkinsonian features
  • cerebellar ataxia
  • weight loss
  • resting tachycardia or impaired heart rate variation
  • abnormal gastrointestinal motility
  • erectile dysfunction and lack of ejaculation
  • anhidrosis, heat intolerance, dry skin, focal hyperhidrosis
  • urinary frequency, urgency, nocturia
Full details

Risk factors

  • older adult age
  • frailty and physical deconditioning
  • use of drugs that impair sympathetic tone
  • volume depletion/anemia
  • autonomic neuropathy (e.g., diabetes mellitus)
  • Parkinson disease
  • dementia with Lewy bodies
  • multiple system atrophy
  • hypertension
Full details

Diagnostic tests

1st tests to order

  • posture test
Full details

Tests to consider

  • tilt-table test
  • plasma norepinephrine
  • deep breathing
  • Valsalva maneuver
  • nerve conduction studies and electromyogram (EMG)
  • quantitative sudomotor axon reflex test (QSART)
  • heart rate variability
  • 24-hour blood pressure monitoring
  • autoimmune antibodies
  • chest CT
  • serum and urine electrophoresis
  • fat-pad biopsy
  • genetic testing
Full details

Treatment algorithm

ACUTE

all patients

Contributors

Authors

Italo Biaggioni, MD

Professor of Medicine and Pharmacology

Vanderbilt University

Nashville

TN

Disclosures

IB is a consultant for Theravance Biopharma, Amneal Pharmaceuticals, Regeneron Pharmaceuticals, Takeda Pharmaceuticals, and Neurawell Therapeutics for development of therapies for orthostatic hypotension and postural tachycardia syndrome. He is also a patent holder for an automated abdominal binder for the treatment of orthostatic hypotension and has submitted a patent application for the use of guanfacine for the treatment of postural tachycardia and chronic fatigue syndromes.

Lucy Norcliffe-Kaufmann, PhD

Assistant Professor

Dysautonomia Center

Department of Physiology and Neuroscience

NYU Langone Medical Center

New York

NY

Disclosures

LNK is a board member of the American Autonomic Society and has received grant support from Theravance Biopharma, PTC Therapeutics, National Institutes of Health, Michael J. Fox Foundation, and the Familial Dysautonomia Foundation. LNK is an author of a number of references cited in this topic.

Horacio Kaufmann, MD

Professor of Neurology

Medicine and Pediatrics

New York University School of Medicine

New York

NY

Disclosures

HK is editor in chief of Clinical Autonomic Research and serves as principal investigator of a clinical trial sponsored by Biogen MA Inc. HK has received consultancy fees from Lilly USA LLC, Biohaven Pharmaceuticals Inc, Takeda Pharmaceutical Company Ltd, Ono Pharma UK Ltd, Lundbeck LLC, and Theravance Biopharma US Inc. HK is an author of a number of references cited in this topic.

Peer reviewers

Phillip A. Low, MD

Robert D. and Patricia E. Kern Professor of Neurology

Mayo Clinic College of Medicine

Rochester

MN

Disclosures

PAL is an author of a reference cited in this topic.

William P. Cheshire, MD

Professor of Neurology

Mayo Clinic

Jacksonville

FL

Disclosures

WPC declares that he has no competing interests.

Alan Moore, MB, FRCPI

Consultant Geriatrician

Beaumont Hospital

Dublin

Ireland

Disclosures

AM has received payment from Shire Pharmaceuticals, manufacturer of midodrine, for providing educational talks, and the department in which he works has received unrestricted educational grants from Shire Pharmaceuticals.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Juraschek SP, Cortez MM, Flack JM, et al. Orthostatic hypotension in adults with hypertension: a scientific statement from the American Heart Association. Hypertension. 2024 Mar;81(3):e16-30.Full text  Abstract

Gibbons CH, Schmidt P, Biaggioni I, et al. The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension. J Neurol. 2017 Aug;264(8):1567-82.Full text  Abstract

Lahrmann H, Cortelli P, Hilz M, et al. EFNS guidelines on orthostatic hypotension. In: Gilhus NE, Barnes MP, Brainin M (eds). European Handbook of Neurological Management. Vol 1, 2nd ed. Oxford: Wiley-Blackwell; 2011.

Shibao C, Lipsitz LA, Biaggioni I; American Society of Hypertension Writing Group. Evaluation and treatment of orthostatic hypotension. J Am Soc Hypertens. 2013 Jul-Aug;7(4):317-24.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
  • Differentials

    • Neurally mediated (vasovagal) syncope
    • Vertigo
    • Nonspecific falls in older people
    More Differentials
  • Guidelines

    • Consensus statement on the definition of neurogenic supine hypertension
    • Guidelines on the diagnosis and management of syncope
    More Guidelines
  • Patient information

    Postural hypotension (low blood pressure when you stand up)

    More Patient information
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