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  2. Postural hypotension
  3. Postural hypotension
Practice Clinical updates

Postural hypotension

BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n922 (Published 23 April 2021) Cite this as: BMJ 2021;373:n922
  1. Artaza Gilani, honorary lecturer, general practitioner in north west London1,
  2. Stephen P Juraschek, assistant professor of medicine2,
  3. Matthew J Belanger, senior resident physician2,
  4. Julie E Vowles, consultant in acute and geriatric medicine3,
  5. S Goya Wannamethee, professor of epidemiology1
  1. 1UCL Research Department of Primary Care and Population Health, University College London Medical School (Royal Free Hospital Campus), London NW3 2PF, UK
  2. 2Harvard Medical School, Beth Israel Deaconess Medical Center, Division of General Medicine, Section for Research, Boston, MA 02215, USA
  3. 3Hillingdon Hospitals NHS Foundation Trust, Uxbridge UB8 3NN, UK
  1. Correspondence to: Artaza Gilani artaza.gilani{at}ucl.ac.uk

What you need to know

  • Postural hypotension is a drop in blood pressure (≥20 mm Hg systolic and/or ≥10 mm Hg diastolic) that occurs within 3 minutes of standing

  • Test for it in people who have symptoms of lightheadedness or dizziness on changing from lying or sitting to standing posture or those with an unexplained fall

  • Age over 60 years, diabetes, Parkinson’s disease, and certain medications increase the risk

  • The aim of treatment is to reduce symptoms (including risk of injury) and improve quality of life, rather than trying to reduce the postural drop in blood pressure

  • Evidence for both non-pharmacological and pharmacological interventions is poor, making it important to identify why a patient has postural hypotension and to address the underlying condition

Postural hypotension, also called orthostatic hypotension, is an abnormal drop in blood pressure on standing. It impairs quality of life and increases risk of falls, cardiovascular disease, depression, dementia, and death.1234 Early detection in patients with symptoms or certain risk factors may prevent some of these complications. Current guidelines for detecting and managing postural hypotension are varied and based on limited evidence. Primary care providers play an important role in screening and detection of postural hypotension and in helping patients make shared treatment decisions to improve symptoms and reduce risk.

Sources and selection criteria

We searched Embase, Medline, the Cochrane Central Register of Controlled Trials, and Web of Science using the terms “orthostatic hypotension,” “postural hypotension,” “orthostatic intolerance,” and “postural intolerance.” We also used personal archived references, which included our published work and National Institute for Health and Care Excellence (NICE) guidelines.

How common is it?

The prevalence of postural hypotension increases with age. One in five community-dwelling adults over 60 years old and one in four people in long term residential care have postural hypotension, as per a systematic review and meta-analysis (26 studies, >25 000 people).5 Two large population based studies in the US suggest it is found in <5% of people aged 45-49 years, almost 15% in those aged 65-69 years, and over 25% of those aged >85 years.6

Postural hypotension is likely to be common in geriatric inpatients.78 Clinical settings, encouragement to mobilise, and frequency of testing may affect prevalence in hospitals.8910

How is it caused?

Postural hypotension occurs with an inadequate or delayed response to fluid shifts in the body on standing. This leads to an exaggerated drop in systolic blood pressure (≥20 mm Hg) and/or diastolic blood pressure (≥10 mm Hg) on standing.9 Figure 1 depicts the mechanism. “Classic” postural hypotension occurs within three minutes of standing, “delayed” postural hypotension occurs after three minutes. Most studies have investigated classic postural hypotension, and less is known about delayed postural hypotension.11

Fig 1
Fig 1

The normal physiological response to change of position from lying to standing: the response is coordinated through neuronal and non-neuronal mechanisms

A coordinated response of the autonomic nervous system helps to maintain blood pressure. Box 1 lists the neurogenic or non-neurogenic conditions that may affect this response and cause postural hypotension. About a quarter of patients with diabetes have postural hypotension, as per a systematic review and meta-analysis (21 studies, 13772 patients).13 High HbA1c, hypertension, and diabetic neuropathy increase its likelihood. About a third of patients with Parkinson’s disease have postural hypotension.14

Box 1

Conditions that can cause postural hypotension1720

Neurogenic causes

  • Neurodegenerative disease—Such as Parkinson’s disease, Parkinson-plus syndromes

  • Peripheral neuropathy—Such as diabetes, vitamin B12 deficiency, renal failure, amyloidosis, rheumatological, autoimmune, and paraneoplastic conditions

Non-neurogenic causes

  • Volume depletion—Anaemia, dehydration, haemorrhage, hyperglycaemia

  • Cardiovascular disease—Aortic stenosis, hypertension, heart failure, atherosclerosis or vascular stiffening, arrhythmias

  • Other—Adrenal insufficiency, physical deconditioning, ageing

Either mechanism

  • Medications—α blockers, antihypertensives, nitrates, diuretics, selective serotonin reuptake inhibitors, tricyclic antidepressants, antipsychotics, β blockers

  • Alcohol consumption

    • Short term: diuretic effect, impairment of vasoconstriction12

    • Long term or chronic: neurotoxic effects

  • Idiopathic

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Medications can cause postural hypotension as an adverse reaction. Individual susceptibility, age, comorbidities and polypharmacy determine whether a patient develops postural hypotension.1516 The number of antihypertensive drugs prescribed may be more predictive of postural hypotension than an individual class of drug.17

Why does it matter?

Postural hypotension worsens physical function and impairs balance and ability to perform activities of daily living.18 Large meta-analyses reported increased risk of falls (odds ratio 1.73, 95% confidence interval 1.50 to 1.991), heart failure (hazard ratio 1.34, 95% CI 1.17 to 1.5219), coronary heart disease (hazard ratio 1.44, 1.18 to 1.7519), stroke (hazard ratio 1.64, 1.13 to 2.372), atrial fibrillation (hazard ratio 1.51, 1.28 to 1.7919), and all-cause mortality (relative risk 1.50, 1.24 to 1.812) with postural hypotension. Small studies point to an increased risk of cognitive impairment, dementia, and depression.34 It is unclear if risk differs between symptomatic and asymptomatic patients and between age groups.

How do patients present?

Symptoms are triggered by changes in posture and usually resolve with lying down or sitting. Patients may present with lightheadedness or dizziness, transient loss of consciousness, or falls. Box 2 lists symptoms of postural hypotension.20 Symptoms may occur first thing in the morning, as the patient gets up from bed, or throughout the day, as they change position from lying to standing, sitting to standing or even lying to sitting. It is unclear how diagnostic these symptoms are, but if these occur in relation to changes in posture, they should prompt a check for postural hypotension.

Box 2

Presenting symptoms of postural hypotension20

Common symptoms

  • Lightheadedness (feeling faint)

  • Dizziness (spinning sensation or feeling off balance)

  • Transient loss of consciousness

  • Falls

Less common, non-specific

  • Blurry vision

  • Visual field deficits

  • Difficulty concentrating

  • Cognitive slowing

  • Weakness

  • Fatigue

  • Shortness of breath

  • Chest pain

  • Backache

  • Lower extremity pain

  • “Coathanger” headache (headache in the suboccipital region and neck pain in the posterior cervical and shoulder regions)

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Some patients have no symptoms and postural hypotension is detected incidentally on clinical examination. In a small observational study, about a third had postural hypotension but were asymptomatic.2122 The clinical significance of asymptomatic postural hypotension is not established.

What to cover on clinical assessment?

Ask about the nature of symptoms, their onset in relation to changes in posture and if they are persistent/recurrent or isolated. Factors such as diurnal variability, food intake, hydration, ambient temperature, prolonged recumbency, and deconditioning can affect symptoms.9 Seek to identify the cause(s) of postural hypotension, which may be multifactorial. Medication history is important, particularly if symptoms appeared after initiation of a drug.

Tailor clinical examination to identify features related to symptoms and probable causes. A patient with palpitations may have a murmur suggestive of structural abnormality of the heart, while a patient who describes slowness of movement and tremor may have hypomimia and rigidity, suggestive of Parkinson’s disease.

Postural blood pressure measurement

The UK’s National Institute for Health and Care Excellence (NICE) guidelines advise assessing for postural hypotension in patients who are symptomatic or those who present with a fall.23

Take lying and standing blood pressure measurements and check for a drop in systolic blood pressure ≥20 mm Hg and/or diastolic blood pressure ≥10 mm Hg within three minutes of standing.23 Measurement beyond three minutes of standing may be necessary if a patient reports symptoms occurring after this time, otherwise delayed postural hypotension may be missed. Guidelines vary widely in recommendations on how to measure postural blood pressure measurements (table 1). It is advisable to take multiple lying and standing measurements.

Table 1

Guidelines regarding the measurement of blood pressure to detect postural hypotension

View this table:

For convenience or practical reasons, sitting and standing (and occasionally lying and sitting) measurements are sometimes used. The optimal thresholds for a diagnosis based on these measurements are not known.323334 If an exaggerated drop in blood pressure is not found, lying and standing measurements may be more likely to detect postural hypotension. Measuring postural hypotension can be time consuming in a busy practice. Involve allied healthcare professionals in taking postural measurements on the day of the appointment, as is done in falls clinics.

Repeating measurements at a later point in time increases detection rates.10 Serial home postural blood pressure measurements (morning and evening), either by patients themselves or their carers, may be considered if feasible and the patient is sufficiently mobile. It may be inappropriate in patients with severe symptoms at high risk of falls who cannot be supported while taking measurements.

Note changes in heart rate when taking lying and standing blood pressure measurements. If postural hypotension is found, an accompanying increase in heart rate of <15 beats per minute may suggest a neurogenic cause,35 and an increase in heart rate of >15 beats per minute may suggest a non-neurogenic cause.35 Heart rate is a non-specific indicator of underlying cause and may not be accurate if, for example, the patient is taking a β blocker.

Whom to screen for postural hypotension?

Screening in the general population is not recommended but may be considered in certain patients. For example, NICE guidelines advise checking for postural hypotension in patients who have hypertension alongside type 2 diabetes or who have hypertension and are aged 80 years and over.23 The American Diabetes Association recommends assessment for postural hypotension during initial evaluation of hypertension in all patients with diabetes, and periodically at follow-up even in the absence of symptoms.36 Consensus recommendations by an expert panel35 suggest screening in patients suspected of, or diagnosed with, any neurodegenerative condition associated with autonomic dysfunction (such as Parkinson’s disease) and in patients with peripheral neuropathies known to be associated with autonomic dysfunction (such as diabetes).

What differential diagnoses to consider?

Patients may experience similar symptoms triggered by meals in post-prandial hypotension.37 Vasovagal syncope (commonly referred to as a “faint”) may be accompanied by an acute drop in blood pressure when standing. It is usually precipitated by emotional stress, pain, heat, dehydration, or a period of prolonged sitting or standing38 and tends to occur in younger, otherwise healthy adults. There may be prodromal symptoms such as sweating, nausea, and pallor before the transient loss of consciousness.

Carotid sinus syndrome causes syncope, near-syncope, or unexplained falls due to carotid sinus hypersensitivity. Like postural hypotension, it is more common in older people39 and is difficult to distinguish clinically. The two conditions cause similar symptoms and may coexist. Tilt-table testing may help in a diagnosis. This is done in a specialist cardiology setting for patients with syncope of uncertain origin. The patient is put under positional or orthostatic stress in a controlled and monitored setting.

What are the investigations?

Investigations are chosen on a case-by-case basis because of the wide range of possible causes, but they may not be necessary if a drug related cause is suspected. Depending on the history, tests in primary care may include:

  • Bloods—full blood count if the patient has chronic bleeding or anaemia, urea and electrolytes, HbA1c for diabetes, vitamin B12

  • Electrocardiograpy—if an arrythmia is suspected

  • Echocardiogram—if a structural heart problem is suspected.

How is it managed?

The aim of treatment is to reduce symptoms and risk of injury. The aim is not to try to normalise the magnitude of the postural fall in blood pressure because its correlation with symptoms22 and the risk of complications is not established. Asymptomatic postural hypotension is not currently treated. Some patients may not meet the defined criteria for a diagnosis of postural hypotension despite having symptoms and home measurements showing a postural drop in blood pressure. Their symptoms are managed as those with confirmed postural hypotension.

Address reversible causes

Some causes of postural hypotension are permanent (such as Parkinson’s disease) and cause recurring symptoms, whereas others are transient (such as anaemia) that can be corrected. Address reversible causes such as drugs, infection, dehydration, and anaemia. Consider stopping or reducing the dose of an offending drug or using a modified-release preparation. Reassess the patient after an appropriate washout period based on the pharmacokinetics and half-life of the specific drug. The withdrawn drug may be replaced by another drug, or the underlying condition may be adequately managed without the drug.

While epidemiological studies show an association between higher HbA1c and postural hypotension, it is uncertain if lowering the HbA1c reduces the incidence or severity of postural hypotension.

Conservative measures to improve symptoms

Help patients understand what postural hypotension is, what causes it, and what may make it worse (box 3). Prolonged standing, eating large meals, drinking alcohol, deconditioning, dehydration, hot environment, taking hot baths or showers, and straining920 may worsen symptoms in some patients. Box 4 lists common non-pharmacological measures that may be suggested in practice. Recent systematic reviews highlight a lack of evidence on these measures.204041 Studies are limited in number, and most are small with short follow-up times. Lower limb and abdominal compression therapy may offer some benefit, but the evidence is of very low quality.40

Box 3

What patients need to know

  • Postural hypotension is a drop in blood pressure on standing or changing position. If you feel lightheaded or dizzy when you stand up, or if you have fallen or fainted after getting up from a sitting or lying position, you may have postural hypotension. Some people with postural hypotension feel fatigue, weakness, or trouble concentrating when changing positions.

  • Postural hypotension affects about 1 in 5 (20%) of adults over the age of 60 years.

  • Your GP can help diagnose it and discuss how best to treat your symptoms.

  • Depending on what’s causing it, postural hypotension may not be eliminated or cured completely. The goal of treatment will be to alleviate your symptoms and lower the risk of having a fall.

  • Simple lifestyle changes may help relieve some symptoms, such as avoiding sudden and quick movements when changing position from sitting to standing or lying to standing.

  • If lifestyle changes aren’t enough to control the symptoms, prescription medication may be helpful. Choosing the right medication for you depends on your symptoms, your overall health, and other medications you may be taking.

  • There is uncertainty about which treatment options work best. Certain medications (fludrocortisone, midodrine, and droxidopa) might relieve your symptoms, but the studies are small in number. If you choose to take a medication, your doctor will closely monitor your health to make sure you are benefiting from the medication, while avoiding any side effects.

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Box 4

Non-pharmacological treatments for postural hypotension

  • Change position slowly and in stages (from lying to sitting to standing), rather than changing from lying to standing in a swift motion

  • Maintain adequate hydration

  • Avoid alcohol, large meals, very warm environments, and hot showers or baths

  • Sleep with the head of the bed elevated

  • Exercise programmes

  • Physical manoeuvres such as crossing the legs while standing and tensing the muscles in the legs and buttocks after standing

  • Lower limb compression

  • Abdominal binders

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Referral and medications

Offer referral to a specialist if symptoms are not controlled or are persistent and frequent, or if the cause is unexplained. Specialist referral is based on the patient’s age, symptoms, and medical conditions. For example, a young patient with repeated unexplained syncopal symptoms and palpitations would be referred to a cardiologist, an older patient with bradykinesia and a shuffling gait would be referred to a neurologist, and an elderly frail patient with multimorbidity and polypharmacy with recurrent falls would be referred to a geriatrician.

Pharmacological treatment is usually started by a specialist if symptoms are not well controlled by conservative measures. Treatment may be continued or modified in primary care. Prescribing practices vary and are governed by local guidelines. In the UK, for example, the use of fludrocortisone for postural hypotension is off-label. Midodrine is indicated only for people with postural hypotension due to autonomic dysfunction, and its use for other types of postural hypotension is off-label.42 Droxidopa does not yet have market authorisation for use in postural hypotension in the UK.

Fludrocortisone, midodrine, and droxidopa may each reduce some of the symptoms of postural hypotension as per systematic reviews and meta-analyses. The evidence is weak and mainly drawn from small randomised controlled trials using different outcome measures and with short follow-up.434445 It is not known how long patients should try treatment before they can expect to see benefit from it. Table 2 lists suggested doses and side effects of these drugs. Plan regular review with the patient and consider increasing the dose if symptoms remain poorly controlled. The drug may be discontinued if side effects worsen a patient’s quality of life.

Table 2

Summary of pharmacological treatment options for postural hypotension (based on NICE evidence summaries,2642 the British National Formulary (BNF), electronic medicines compendium (emc), and American Autonomic Society and National Parkinson Foundation recommendations35)

View this table:

Special considerations in hypertensive patients

Clinicians may worry that tight control of blood pressure in a hypertensive patient may cause or worsen postural hypotension.46 It may not be necessary to compromise blood pressure targets in people with postural hypotension, rather uncontrolled hypertension may worsen postural hypotension.46 In a large randomised controlled trial, more intensive blood pressure targets (systolic blood pressure ≤120 mm Hg) were not more likely to cause postural hypotension than standard targets (systolic blood pressure ≤140 mm Hg), but syncope was more common.47 A recent systematic review and meta-analysis showed that lower blood pressure treatment goals decreased the risk of postural hypotension.48

Different drug classes (such as α blockers, β blockers, calcium channel blockers, diuretics, ACE inhibitors, and angiotensin II antagonists) confer different risk of postural hypotension,17 and reports linking particular antihypertensive drugs to postural hypotension are inconsistent.15 The number of drugs taken may be more predictive of postural hypotension than individual drug classes.17

If a patient with postural hypotension is taking multiple drugs, discontinuing any one of them is likely to reduce symptoms. The choice of drug depends on the individual circumstances of a patient. For example, if a patient with heart failure who is taking a β blocker, ACE inhibitor, and α blocker develops postural hypotension, it would be reasonable to reduce the dose (or stop altogether) the α blocker in the first instance. The β blocker and ACE inhibitor are more likely to be cardioprotective and therefore important prognostically for a patient with heart failure. Reassess patients for symptoms of postural hypotension and monitor blood pressure, either through home blood pressure readings or 24 hour blood pressure monitoring.

Postural hypertension

Less common than postural hypotension, a patient’s blood pressure may sometimes rise on standing.49 Postural hypertension remains an under-appreciated clinical finding. There is no consensus on what defines an “exaggerated” increase in blood pressure. Most studies consider it an increase in systolic blood pressure ≥20 mm Hg. More recent definitions mirror the thresholds for postural hypotension and include an increase in diastolic blood pressure ≥10 mm Hg as well.49 Its prevalence ranges from 1.1% to almost 40%, depending on the cohort studied and definition used.49 Some observational studies suggest it may increase risk of cardiovascular morbidity, including myocardial infarction and stroke, cardiovascular-related mortality and all-cause mortality.49 Further research is needed on the clinical relevance of postural hypertension and the risk of adverse health outcomes to determine if postural variability of blood pressure (regardless of whether it is an increase or decrease) is a worrying clinical sign.

Questions for future research

  • What are the health implications of delayed versus classic postural hypotension?

  • What is the clinical significance of asymptomatic postural hypotension?

  • What is the best way to measure or detect postural hypotension?

  • What is the correlation between improvement in the magnitude of the drop in postural blood pressure and symptoms, and how does this translate into reduced risk of complications?

  • What non-pharmacological management options are effective at reducing symptoms of postural hypotension and the risk of a fall?

Additional educational resources

Information resources for patients

Education into practice

  • What is the protocol for taking postural blood pressure measurements at your clinic?

  • How would you approach a patient with postural hypotension related to a medication?

How patients were involved in the creation of this article

A patient partner through the Patient and Family Advisory Council at Beth Israel Deaconess Medical Center reviewed the manuscript and provided feedback on sections related to education, management, and goals of therapy for postural hypotension. She was instrumental in creating the box on what patients need to know. We are grateful for her input.

Acknowledgments

We thank general practitioners Nabeel Ansari and Alison Rackham for providing advice on items that would be particularly helpful for clinicians in primary care. We thank Tobie Atlas for providing invaluable feedback from the perspective of patients.

Footnotes

  • Contributors: AG had the idea for the article, performed the literature search, and wrote the article. All authors then reviewed and revised the content. All authors approved the final version to be published. AG is the guarantor.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.

  • Funding: AG was funded by the National Institute for Health Research (NIHR) School for Primary Care Research. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. SPJ is funded by the National Heart, Lung, and Blood Institute.

  • Provenance and peer review: Commissioned, based on an idea from the author; externally peer reviewed

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