Top Things to Know: Orthostatic Hypotension in Hypertensive Adults

Published: January 11, 2024

  1. Orthostatic hypotension (OH) is defined as a sustained reduction in systolic blood pressure of at least 20mmHg or diastolic blood pressure of 10mmHg within 3 minutes of standing and is common among adults with uncontrolled hypertension (HTN) and is frequently cited because of HTN treatment.
  2. OH is driven by gravitational redistribution of about 300-800 cc’s of fluid to the lower extremities and splanchnic vessels upon standing.
  3. OH increases with age affecting about 10% of adults 60 – 65 and increases to 15%-30% in adults over age 65. This is partly due to impairments in autonomic reflex with age.
  4. OH is an independent risk factor of mortality - that is linked to higher hospital admissions. Persons with OH have a higher risk of developing heart failure, atrial fibrillation, coronary heart disease and myocardial infarction.
  5. There are four clinical presentations for OH or characterizations as described in this paper:
    1. Classic OH caused by autonomic dysfunction.
    2. Hypertensive OH caused by reduced diastolic filling due to left ventricular hypertrophy/arterial stiffness.
    3. Pseudo OH – “threshold effect” (systolic change threshold of 30 mm Hg among patients with hypertension)
    4. Pseudo OH – measurement error
  6. Non-pharmacologic approaches to managing OH such as compression garments along with fluid and sodium management considerations are discussed in this statement.
  7. The effects of antihypertensive treatments on symptomatic OH and the antihypertensive drugs that can be used in adults with symptomatic OH are reviewed in this paper.
  8. Pharmacologic treatment for specific etiologies such as neurogenic OH, isolated supine HTN in patients with severe neurogenic OH, and hypertension with intermittent hypotensive events are examined in this paper.
  9. When OH is identified, finding its etiology will be an important first step for clinicians in treating this condition. Non-pharmacological interventions are first-line steps regardless of the etiology. Treatment can be complex and nuanced.
  10. More research is needed to adequately understand OH and management of it.


Juraschek SP, Cortez MM, Flack JM, Ghazi L, Kenny RA, Rahman M, Spikes T, Shibao CA, Biaggioni I; on behalf of the American Heart Association Council on Hypertension. Orthostatic hypotension in adults with hypertension:a scientific statement from the American Heart Association. Hypertension. Published online January 11, 2024. doi: 10.1161/HYP.0000000000000236