Guideline sources The following summarized guidelines for the evaluation and management of orthostatic hypotension (OH) are prepared by our editorial team based on guidelines from the International Liaison Committee on Resuscitation (ILCOR 2019), the American Heart Association (AHA/HRS/ACC 2017), and the European Federation of Neurological Societies (EFNS 2006). 1 2 3 Guidelines 1. Diagnostic investigations Initial evaluation: Obtain the following as part of the initial evaluation of patients with suspected OH: structured history taking detailed physical examination supine and upright BP measurements 12-lead ECG recording active standing or head-up tilt, ideally with continuous assessment of BP and HR for 3 min. B https://web.pathway.md/diseases/rec8C2EnGrof7C3iY 1/4 6/30/23, 1:23 AM Orthostatic hypotension Pathway Obtain further autonomic nervous system screening tests, with other appropriate investigations, depending on the possible etiology of the underlying disorder. B Head-up tilt testing: Conduct passive head-up tilt testing to an angle 60-80 degrees for 3 minutes to diagnose OH. E Classify head-up tilt testing as positive if systolic BP falls below 20 mmHg and diastolic BP below 10 mmHg of baseline. (expert opinion. 2. Medical management Fludrocortisone: Administer fludrocortisone as first line drug-monotherapy of OH. B Advise patients to maintain a high dietary salt and adequate fluid intake to obtain full benefits from fludrocortisone treatment. B Midodrine: Administer midodrine (2.5 mg PO TID, increasing gradually up to 10 mg PO TID) as first-line treatment, either alone or combined with fludrocortisone. A Administer the last dose of midodrine at least 4 hours before going to sleep and monitor for the development of supine hypertension. A Droxidopa: droxidopa reduces OH in a dosage between 200 and 400 mg per day. It is the only effective treatment for patients with dopamine -hydroxylase deficiency. In all studies reviewed, no major side effects were reported. Future studies will have to investigate which patient groups benefit most from this drug. A Octreotide: consider pre-prandial octreotide (25-50 g subcutaneous, 30 minutes before meals) to reduce post-prandial OH. C 3. Nonpharmacologic interventions Physical and nutritional measures: Physical measures that may improve OH include leg crossing, squatting, elastic abdominal binders and stockings, and careful exercise. E Increased water (2-2.5 L/day) and salt ingestion (> 8 g or 150 mmol/day) effectively improve OH. E 4. Therapeutic procedures Physical counterpressure maneuvers: Advise the use of any type of physical counterpressure maneuvers by individuals with acute symptoms of presyncope from vasovagal or orthostatic causes in the first aid setting. B https://web.pathway.md/diseases/rec8C2EnGrof7C3iY 2/4 6/30/23, 1:23 AM Orthostatic hypotension Pathway Recognize that we suggest that lower-body physical counterpressure maneuvers such as leg crossing and tensing or squatting are preferable to upper-body and abdominal physical counterpressure maneuvers. B 5. Specific circumstances Patients with syncope: advise acute water ingestion in patients with syncope caused by neurogenic OH for occasional, temporary relief. B Show 9 more 6. Patient education Physical and nutritional measures: counsel patients on the various factors that influence BP, and specific elements that must be avoided (foods, habits, positions and drugs). E Clinical findings Symptoms Past medical history Blurry vision Myocardial infarction Chest pain VHD Dizziness Vital signs Fatigue Headache Orthostatic hypotension Lightheadedness HR Nausea systolic BP Neck pain Hematological findings Palpitations Syncope Anemia Weakness Medication history Antihypertensive agents Integument exam Dehydration ECG findings Cardiac arrhythmias References https://web.pathway.md/diseases/rec8C2EnGrof7C3iY 3/4 6/30/23, 1:23 AM Orthostatic hypotension Pathway 1. Lahrmann H, Cortelli P, Hilz M et al. EFNS guidelines on the diagnosis and management of orthostatic hypotension. Eur J Neurol. 2006 Sep;13 9 930 6. Open 2. Soar J, Maconochie I, Wyckoff MH et al. 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation. 2019 Dec 10;140 24):e826- e880. Open 3. Writing Committee Members, Shen WK, Sheldon RS et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2017 Aug;14 8):e155-e217. Open https://web.pathway.md/diseases/rec8C2EnGrof7C3iY 4/4