Orthostatic hypotension

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 21 Apr 2025

Last updated: 13 Dec 2024

Orthostatic hypotension (OH) is an independent predictor of mortality and the cause of significant morbidity associated with falls.

A common problem in frail older people. OH-related hospitalizations increase markedly with age.

Common causes include drugs (e.g., alpha-blockers, central sympatholytics, tricyclic antidepressants, phosphodiesterase-5 inhibitors, and antihypertensives, including beta-blockers), diseases causing peripheral neuropathy (e.g., diabetes mellitus and amyloidosis), and synucleinopathies (i.e., Parkinson disease, dementia with Lewy bodies, pure autonomic failure, and multiple system atrophy or Shy-Drager syndrome).

Acute or subacute onset suggests an autoimmune or paraneoplastic disorder.

OH is increasingly recognized as a common comorbidity of hypertension, both because of the pathophysiology of hypertension itself, and also because the measurement of OH is derived from the difference between two blood pressures (lying or sitting, and standing), the absolute value of which will be greater with a higher starting blood pressure.

Treatment consists of addressing any underlying pathology, when possible, followed by discontinuing or reducing the dose of aggravating drugs, and introducing nonpharmacologic countermeasures (e.g., liberalization of salt intake, use of abdominal binders or compression stockings). Short-acting vasopressors, such as midodrine, or droxidopa (a norepinephrine prodrug) are adjunctive therapies when nonpharmacologic measures are insufficient. Volume expansion (using mineralocorticoid therapy) may be used after these therapies due to limited evidence for its use, and a number of undesirable adverse effects.

Definition

OH is defined as a fall in systolic blood pressure of at least 20 mmHg (at least 30 mmHg in patients with hypertension) and/or a fall in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing.[1] When OH has an underlying neurogenic cause (e.g., peripheral neuropathy or synucleinopathies) it is associated with a blunted increase in heart rate, typically less than 15 bpm.[2]

OH becomes clinically significant if it is accompanied by symptoms of cerebral hypoperfusion, which can lead to syncope and falls.[3] OH is associated with increased risk of dementia and cardiovascular disease, and is an independent risk factor for all-cause mortality.[4][5][6] This topic concentrates on OH caused by autonomic problems.

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

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

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

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

Disclosures

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

William P. Cheshire, MD

Professor of Neurology

Mayo Clinic

Jacksonville

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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Orthostatic hypotension

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

all patients

Contributors

Authors

Italo Biaggioni, MD

Disclosures

Lucy Norcliffe-Kaufmann, PhD

Disclosures

Horacio Kaufmann, MD

Disclosures

Peer reviewers

Phillip A. Low, MD

Disclosures

William P. Cheshire, MD

Disclosures

Alan Moore, MB, FRCPI

Disclosures

References

Key articles

Reference articles

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

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice