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Mechanisms, causes, and evaluation of orthostatic hypotension

Horacio Kaufmann, MD
Norman M Kaplan, MD
Section Editor
Michael J Aminoff, MD, DSc
Deputy Editor
Janet L Wilterdink, MD


When autonomic reflexes are impaired or intravascular volume is markedly depleted, a significant reduction in blood pressure occurs upon standing, a phenomenon termed orthostatic hypotension. Orthostatic hypotension can cause dizziness, syncope, and even angina or stroke.

Symptomatic falls in blood pressure after standing or eating are a frequent clinical problem. The prevalence of orthostatic hypotension varies from 5 to 20 percent in different reports. Many disorders can cause orthostatic hypotension, which can also be a symptom of acute or chronic volume depletion as well as a side effect of drugs, particularly antihypertensives. A related problem, postprandial hypotension (a fall in blood pressure occurring 15 to 90 minutes after meals) is also common in older subjects.

Chronic orthostatic intolerance describes the association of lightheadedness, dizziness, faintness, or syncope that occurs with prolonged standing or upright posture. These symptoms may be sometimes associated with an exaggerated tachycardia but little or no fall in blood pressure, a disorder that is called the postural tachycardia syndrome (POTS).

This topic will review the pathogenesis and causes of orthostatic and postprandial hypotension. The treatment of these syndromes is discussed separately. POTS is also discussed separately (See "Treatment of orthostatic and postprandial hypotension" and "Postural tachycardia syndrome".)


Assumption of the upright posture results in the pooling of 500 to 1000 mL of blood in the lower extremities and splanchnic circulation, which initiates the following sequence [1]:


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Literature review current through: Sep 2016. | This topic last updated: Feb 2, 2015.
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  1. Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res 2011; 21:69.
  2. Shibao C, Grijalva CG, Raj SR, et al. Orthostatic hypotension-related hospitalizations in the United States. Am J Med 2007; 120:975.
  3. Sathyapalan T, Aye MM, Atkin SL. Postural hypotension. BMJ 2011; 342:d3128.
  4. Huang CC, Sandroni P, Sletten DM, et al. Effect of age on adrenergic and vagal baroreflex sensitivity in normal subjects. Muscle Nerve 2007; 36:637.
  5. Finucane C, O'Connell MD, Fan CW, et al. Age-related normative changes in phasic orthostatic blood pressure in a large population study: findings from The Irish Longitudinal Study on Ageing (TILDA). Circulation 2014; 130:1780.
  6. Rutan GH, Hermanson B, Bild DE, et al. Orthostatic hypotension in older adults. The Cardiovascular Health Study. CHS Collaborative Research Group. Hypertension 1992; 19:508.
  7. de la Iglesia B, Ong AC, Potter JF, et al. Predictors of orthostatic hypotension in patients attending a transient ischaemic attack clinic: database study. Blood Press 2013; 22:120.
  8. van Hateren KJ, Kleefstra N, Blanker MH, et al. Orthostatic hypotension, diabetes, and falling in older patients: a cross-sectional study. Br J Gen Pract 2012; 62:e696.
  9. Valbusa F, Labat C, Salvi P, et al. Orthostatic hypotension in very old individuals living in nursing homes: the PARTAGE study. J Hypertens 2012; 30:53.
  10. Fotherby MD, Potter JF. Orthostatic hypotension and anti-hypertensive therapy in the elderly. Postgrad Med J 1994; 70:878.
  11. Feldstein C, Weder AB. Orthostatic hypotension: a common, serious and underrecognized problem in hospitalized patients. J Am Soc Hypertens 2012; 6:27.
  12. Aung AK, Corcoran SJ, Nagalingam V, et al. Prevalence, associations, and risk factors for orthostatic hypotension in medical, surgical, and trauma inpatients: an observational cohort study. Ochsner J 2012; 12:35.
  13. Kaufmann H. Neurally mediated syncope and syncope due to autonomic failure: differences and similarities. J Clin Neurophysiol 1997; 14:183.
  14. Téllez MJ, Norcliffe-Kaufmann LJ, Lenina S, et al. Usefulness of tilt-induced heart rate changes in the differential diagnosis of vasovagal syncope and chronic autonomic failure. Clin Auton Res 2009; 19:375.
  15. Robertson D, Robertson RM. Causes of chronic orthostatic hypotension. Arch Intern Med 1994; 154:1620.
  16. Metzler M, Duerr S, Granata R, et al. Neurogenic orthostatic hypotension: pathophysiology, evaluation, and management. J Neurol 2013; 260:2212.
  17. Kaufmann H, Biaggioni I. Autonomic failure in neurodegenerative disorders. Semin Neurol 2003; 23:351.
  18. Kaufmann H, Nahm K, Purohit D, Wolfe D. Autonomic failure as the initial presentation of Parkinson disease and dementia with Lewy bodies. Neurology 2004; 63:1093.
  19. Freeman R. Pure autonomic failure: an immaculate misconception? Neurology 2004; 63:953.
  20. Fedorowski A, Melander O. Syndromes of orthostatic intolerance: a hidden danger. J Intern Med 2013; 273:322.
  21. Ganjehei L, Massumi A, Razavi M, Wilson JM. Orthostatic hypotension as a manifestation of vitamin B12 deficiency. Tex Heart Inst J 2012; 39:722.
  22. Ng WF, Stangroom AJ, Davidson A, et al. Primary Sjogrens syndrome is associated with impaired autonomic response to orthostasis and sympathetic failure. QJM 2012; 105:1191.
  23. Klein CM, Vernino S, Lennon VA, et al. The spectrum of autoimmune autonomic neuropathies. Ann Neurol 2003; 53:752.
  24. Vernino S, Sandroni P, Singer W, Low PA. Invited Article: Autonomic ganglia: target and novel therapeutic tool. Neurology 2008; 70:1926.
  25. McKeon A, Lennon VA, Lachance DH, et al. Ganglionic acetylcholine receptor autoantibody: oncological, neurological, and serological accompaniments. Arch Neurol 2009; 66:735.
  26. DiBona GF. Renal neural activity in hepatorenal syndrome. Kidney Int 1984; 25:841.
  28. Perlmuter LC, Sarda G, Casavant V, Mosnaim AD. A review of the etiology, associated comorbidities, and treatment of orthostatic hypotension. Am J Ther 2013; 20:279.
  29. Tonkin AL, Wing LM. Effects of age and isolated systolic hypertension on cardiovascular reflexes. J Hypertens 1994; 12:1083.
  30. Abdel-Rahman TA. Orthostatic hypotension before and after meal intake in diabetic patients and healthy elderly people. J Family Community Med 2012; 19:20.
  31. Jansen RW, Lipsitz LA. Postprandial hypotension: epidemiology, pathophysiology, and clinical management. Ann Intern Med 1995; 122:286.
  32. Zanasi A, Tincani E, Evandri V, et al. Meal-induced blood pressure variation and cardiovascular mortality in ambulatory hypertensive elderly patients: preliminary results. J Hypertens 2012; 30:2125.
  33. Khurana RK. Coat-hanger ache in orthostatic hypotension. Cephalalgia 2012; 32:731.
  34. Robertson D, Kincaid DW, Haile V, Robertson RM. The head and neck discomfort of autonomic failure: an unrecognized aetiology of headache. Clin Auton Res 1994; 4:99.
  35. Bleasdale-Barr KM, Mathias CJ. Neck and other muscle pains in autonomic failure: their association with orthostatic hypotension. J R Soc Med 1998; 91:355.
  36. Kaufmann H. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure and multiple system atrophy. Clin Auton Res 1996; 6:125.
  37. Benrud-Larson LM, Dewar MS, Sandroni P, et al. Quality of life in patients with postural tachycardia syndrome. Mayo Clin Proc 2002; 77:531.
  38. Galizia G, Convertino G, Testa G, et al. Transient ischemic attack caused by delayed orthostatic hypotension in an elderly hypertensive patient. Geriatr Gerontol Int 2012; 12:565.
  39. Luukinen H, Koski K, Laippala P, Airaksinen KE. Orthostatic hypotension and the risk of myocardial infarction in the home-dwelling elderly. J Intern Med 2004; 255:486.
  40. Kaplan NM. The promises and perils of treating the elderly hypertensive. Am J Med Sci 1993; 305:183.
  41. Gibbons CH, Freeman R. Delayed orthostatic hypotension: a frequent cause of orthostatic intolerance. Neurology 2006; 67:28.
  42. Gupta V, Lipsitz LA. Orthostatic hypotension in the elderly: diagnosis and treatment. Am J Med 2007; 120:841.
  43. Fedorowski A, Stavenow L, Hedblad B, et al. Orthostatic hypotension predicts all-cause mortality and coronary events in middle-aged individuals (The Malmo Preventive Project). Eur Heart J 2010; 31:85.
  44. Fedorowski A, Stavenow L, Hedblad B, et al. Consequences of orthostatic blood pressure variability in middle-aged men (The Malmö Preventive Project). J Hypertens 2010; 28:551.
  45. Verwoert GC, Mattace-Raso FU, Hofman A, et al. Orthostatic hypotension and risk of cardiovascular disease in elderly people: the Rotterdam study. J Am Geriatr Soc 2008; 56:1816.
  46. Masaki KH, Schatz IJ, Burchfiel CM, et al. Orthostatic hypotension predicts mortality in elderly men: the Honolulu Heart Program. Circulation 1998; 98:2290.
  47. Rose KM, Eigenbrodt ML, Biga RL, et al. Orthostatic hypotension predicts mortality in middle-aged adults: the Atherosclerosis Risk In Communities (ARIC) Study. Circulation 2006; 114:630.
  48. Luukinen H, Koski K, Laippala P, Kivelä SL. Prognosis of diastolic and systolic orthostatic hypotension in older persons. Arch Intern Med 1999; 159:273.
  49. Maule S, Milazzo V, Maule MM, et al. Mortality and prognosis in patients with neurogenic orthostatic hypotension. Funct Neurol 2012; 27:101.
  50. Fagard RH, De Cort P. Orthostatic hypotension is a more robust predictor of cardiovascular events than nighttime reverse dipping in elderly. Hypertension 2010; 56:56.
  51. Xin W, Lin Z, Li X. Orthostatic hypotension and the risk of congestive heart failure: a meta-analysis of prospective cohort studies. PLoS One 2013; 8:e63169.
  52. Fedorowski A, Engström G, Hedblad B, Melander O. Orthostatic hypotension predicts incidence of heart failure: the Malmö preventive project. Am J Hypertens 2010; 23:1209.
  53. Jones CD, Loehr L, Franceschini N, et al. Orthostatic hypotension as a risk factor for incident heart failure: the atherosclerosis risk in communities study. Hypertension 2012; 59:913.
  54. Fedorowski A, Hedblad B, Engström G, et al. Orthostatic hypotension and long-term incidence of atrial fibrillation: the Malmö Preventive Project. J Intern Med 2010; 268:383.
  55. Gangavati A, Hajjar I, Quach L, et al. Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc 2011; 59:383.
  56. Ooi WL, Hossain M, Lipsitz LA. The association between orthostatic hypotension and recurrent falls in nursing home residents. Am J Med 2000; 108:106.
  57. Kruit MC, Thijs RD, Ferrari MD, et al. Syncope and orthostatic intolerance increase risk of brain lesions in migraineurs and controls. Neurology 2013; 80:1958.
  58. Viramo P, Luukinen H, Koski K, et al. Orthostatic hypotension and cognitive decline in older people. J Am Geriatr Soc 1999; 47:600.
  59. Heims HC, Critchley HD, Martin NH, et al. Cognitive functioning in orthostatic hypotension due to pure autonomic failure. Clin Auton Res 2006; 16:113.
  60. Kuo HK, Sorond F, Iloputaife I, et al. Effect of blood pressure on cognitive functions in elderly persons. J Gerontol A Biol Sci Med Sci 2004; 59:1191.
  61. Matsubayashi K, Okumiya K, Wada T, et al. Postural dysregulation in systolic blood pressure is associated with worsened scoring on neurobehavioral function tests and leukoaraiosis in the older elderly living in a community. Stroke 1997; 28:2169.
  62. Benvenuto LJ, Krakoff LR. Morbidity and mortality of orthostatic hypotension: implications for management of cardiovascular disease. Am J Hypertens 2011; 24:135.
  63. Pezzoli M, Garzaro M, Pecorari G, et al. Orthostatic hypotension and psychiatric comorbidities in patients with dizziness. Am J Otolaryngol 2012; 33:432.
  64. Perlmuter LC, Sarda G, Casavant V, et al. A review of orthostatic blood pressure regulation and its association with mood and cognition. Clin Auton Res 2012; 22:99.
  65. Czajkowska J, Ozhog S, Smith E, Perlmuter LC. Cognition and hopelessness in association with subsyndromal orthostatic hypotension. J Gerontol A Biol Sci Med Sci 2010; 65:873.