Orthostatic Hypotension

What is orthostatic hypotension?

Orthostatic hypotension is a sudden drop in blood pressure when you stand from a seated or prone (lying down) position. You may feel dizzy or even faint.

Orthostatic means an upright posture. Hypotension is low blood pressure. This type of low blood pressure is also called postural hypotension.

What is blood pressure?

Blood pressure measures the force of blood against artery walls as your heart pumps blood through your body’s circulatory system. Blood pressure includes two measurements in millimeters of mercury (mmHg):

• Systolic: Arterial pressure when your heart beats and fills arteries with blood.
• Diastolic: Arterial pressure when your heart’s at rest or between beats.

Your healthcare provider records blood pressure as systolic over diastolic. Healthy blood pressure for most people is below 120/80 millimeters of mercury. A reading below 90/60 millimeters of mercury is considered low blood pressure.

What BP is orthostatic hypotension?

There’s no set number for orthostatic hypotension. Healthcare providers define orthostatic hypotension based on individual blood pressure and how low it goes when you stand up. You have orthostatic hypotension if your blood pressure drops more than 20 millimeters of mercury in systolic pressure or 10 millimeters of mercury in diastolic pressure within three minutes of standing up.

Who might get orthostatic hypotension?

Anyone can get orthostatic hypotension. The condition becomes more common as you age. These factors increase your risk:

• Anemia or vitamin B12 deficiency.
• Dehydration from diarrhea, vomiting or diuretics.
• Endocrine problems, including diabetes, thyroid disease and Addison disease.
• Heart conditions, including arrhythmias and heart valve disease.
• Medications for high blood pressure (hypertension), heart disease and depression.
• Neurological problems, such as Parkinson disease and dementia.
• Pregnancy, especially during the first 24 weeks.
• Prolonged immobility because of illness, including pregnancy bed rest.

How common is orthostatic hypotension?

Orthostatic hypotension affects roughly 20% of older people, especially those who live in long-term care residences. It’s also common among people who’ve been on bed rest or given birth recently. Also, teens having growth spurts can experience orthostatic hypotension.

What are the symptoms?

Orthostatic hypotension happens more frequently — and with more severe symptoms — in the morning. That’s because blood pressure is normally at its lowest when you wake up in the morning.

Some people don’t experience any orthostatic hypotension symptoms. Others find that hot temperatures (from the weather, a fever or even a hot tub or shower) make symptoms worse.

The main symptom of orthostatic hypotension is dizziness or lightheadedness when you stand. You should feel better when you sit or lie down. Some people faint (syncope).

Other orthostatic hypotension symptoms include:

• Blurred vision.
• Chest pain, shoulder pain or neck pain.
• Difficulty concentrating.
• Fatigue or weakness.
• Headaches.
• Heart palpitations.
• Nausea or feeling hot and sweaty.
• Shortness of breath (dyspnea).

What causes orthostatic hypotension?

When you’re sitting or lying down, blood from veins in your legs flows easily to your heart. When you stand up, blood in your legs and feet has a harder time reaching your heart. There’s less blood available for your heart to send to organs and muscles. As a result, your blood pressure temporarily drops.

Orthostatic hypotension causes may include:

• Your heart can’t pump as much blood as it should.
• Your autonomic nervous system (which usually brings your blood pressure back to normal) isn’t working right.
• You have Parkinson disease, Lewy body dementia or multiple system atrophy.
• You’ve been lying down a long time (like a pregnant person on bed rest).
• Your blood volume is low because you’ve lost blood or fluids (dehydration).
• You have an issue with your adrenal gland.
• Your body’s reacting to a medication you’re taking.

How is orthostatic hypotension diagnosed?

Your healthcare provider will check your blood pressure while you’re seated, lying down and standing. They’ll examine you and ask questions about your medical history.

You may also get one or more of these tests:

• Blood tests to check for conditions like diabetes and anemia.
• Echocardiogram (echo) to check your heart’s pumping action.
• Electrocardiogram (EKG) to test for heart rhythm changes.
• Exercise stress test to measure heart rate during physical exertion.
• Portable EKG devices (Holter monitor) to measure heart rhythm.
• Tilt table test to safely measure blood pressure, heart rate and heart rhythm while you lie on a table that moves from horizontal to vertical.

How do you fix orthostatic hypotension?

Orthostatic hypotension treatments vary by what’s causing it.

Treatments may include:

• Treating a condition or disease that’s causing orthostatic hypotension.
• Changing the dose of a medication that causes orthostatic hypotension or switching to a different drug.
• Sitting up in bed if you’re on bed rest.
• Wearing elastic stockings on your legs.
• Taking in fluids and salt if you have dehydration.

What medications/treatments are used?

Rarely, people with orthostatic hypotension need medications to increase blood volume and pressure. These medications include:

• Droxidopa.
• Erythropoiesis-stimulating agents (ESAs, such as Procrit® or Epogen®).
• Desmopressin (Nocdurna® or DDAVP®).
• Octreotide (Bynfezia Pen™ or Mycapssa®).
• Fludrocortisone.
• Midodrine hydrochloride.
• Pyridostigmine (Mestinon® or Regonol®).

Side effects of the treatment

Possible side effects of drugs for orthostatic hypotension include:

• Numbness.
• Itching.
• Headaches.
• Swelling.
• Low potassium levels.
• Heart failure.

What are the complications of orthostatic hypotension?

People with orthostatic hypotension may have a higher risk of:

• Bone fractures or concussions from falls when you feel dizzy or faint.
• Postprandial hypotension, low blood pressure 30 minutes to two hours after eating (particularly a high-carbohydrate meal).
• Shock or organ failure if blood pressure stays too low.
• Stroke or heart disease from fluctuations in blood pressure.
• Supine hypotension, low blood pressure that occurs when lying down.

How can I reduce my risk of orthostatic hypotension?

If you’re prone to orthostatic hypotension, these steps can reduce symptoms:

• Keep your temperature moderate: Don’t take very hot baths or showers.
• Stay hydrated: Drink plenty of water, limit alcohol and avoid heavy, high-carbohydrate meals.
• Don’t sleep flat: Elevate your head at night by using more pillows or tilting the mattress.
• Prepare before standing: Give yourself more time to move into a standing position after sitting or lying down. Have something sturdy nearby to hold onto when you stand up.
• Move your muscles: March your feet if you must stand for prolonged periods. Do isometric exercises (squeeze a soft rubber ball or towel, or clench and unclench your hands) to raise blood pressure before standing.
• Improve blood circulation and pressure: Wear compression stockings or an abdominal binder (elastic that compresses your abdomen).

What can I expect if I have orthostatic hypotension?

Most people with orthostatic hypotension can manage symptoms by taking preventive steps. For example, you may need to move more slowly into a standing position. The condition rarely causes long-term problems.

Outlook for orthostatic hypotension

There’s no cure for orthostatic hypotension. However, you can improve your symptoms by following your healthcare provider’s recommendations, such as:

• Taking medication.
• Eating small meals.
• Drinking more fluids.
• Wearing compression stockings.

When should I see my healthcare provider?

You should call your healthcare provider if you often get dizzy when you stand up. Contact them even if this only happens some of the time.

When should I go to the ER?

Get immediate treatment if you have:

• Chest pain.
• Falls or fainting.
• Trouble with your balance or coordination.
• Suspected bone fractures or head injuries from falls.
• Blood or a black color in your poop.
• Signs of shock (cold, sweaty skin, rapid breathing, blue skin tone and weak pulse).

What questions should I ask my doctor?

You may want to ask your healthcare provider:

• Why do I have orthostatic hypotension?
• What’s the best treatment for orthostatic hypotension?
• Could medications be causing my symptoms? Should I change medications?
• What changes should I make to manage symptoms?
• What signs of complications should I watch for?

Are orthostatic hypotension and postural tachycardia syndrome (POTS) the same condition?

Postural tachycardia syndrome, or POTS, causes symptoms similar to orthostatic hypotension. Both cause dizziness or fainting upon standing. Along with a drop in blood pressure, POTS causes a heart rate increase of 30 to 40 beats per minute within 10 minutes of standing. With orthostatic hypotension, your heart rate doesn’t increase.

POTS is less common than orthostatic hypotension.

A note from Cleveland Clinic

Orthostatic hypotension symptoms can be unsettling. They may even be dangerous if you lose your balance, fall or pass out. Symptoms often improve when you change how you move into a standing position. Tell your healthcare provider about your symptoms. You may need to change your medications to reduce or prevent symptoms. In more severe cases, your provider may prescribe medicine to improve blood flow and pressure.