Rational Pharmacotherapy in Cardiology

Advanced search

Orthostatic Hypotension: Definition, Pathophysiology, Classification, Prognostic Aspects, Diagnostics and Treatment

Full Text:


The urgency of the problem of orthostatic hypotension (OH) has increased in recent years. It was due to the high prevalence and its adverse effect on the prognosis and  quality of life of patients, especially the elderly and  oldest old. The purpose of this review was to summarize the contemporary domestic and foreign literature data  about disease. The article presents an updated definition of OH, modern classification, pathophysiology, feature of the  course  of OH in the  elderly, recommendations for diagnosis and  treatment. Particular attention is paid to reviewing the  results of scientific research on the  influence of OH on the  risk of developing coronary  and  cerebrovascular events  and  overall mortality. OH is one  of the  forms  of orthostatic tolerance and diagnostic criteria were determined by the 2011 Consensus as a sustained fall of systolic blood pressure by at least 20 mm Hg and/or a diastolic blood pressure by 10 mm Hg within 3 min of standing. The prevalence of OH ranges depending on the age of the patients and the presence of a number of concomitant diseases: from 6% in healthy people without arterial hypertension up to 50% or more in people older than 75 years with a comorbid pathology. OH is an independent predictor of overall mortality and adverse  cardiovascular events.  OH is associated with an increased risk of serious adverse  cerebrovascular and  coronary  events,  and  may also contribute to cognitive impairment and  the  development of dementia. For today, we have three  clinical options OH: classical, early and delayed OH. In addition, OH is classified based  on etiology – primary and secondary; and pathophysiological principle – neurogenic OH and not a neurogenic OH (or functional). The algorithm for identifying patients with a high risk of development of OH and diagnostic methods are also presented. Non-medicamentous and medicamentous methods of OH treatment are considered.

About the Authors

O. D. Ostroumova
A.I. Evdokimov Moscow State University of Medicine and Dentistry; I.M. Sechenov First Moscow State Medical University (Sechenov University)
Russian Federation

Olga D. Ostroumova – MD, PhD, Professor, Chair of Faculty Therapy and Occupational Diseases, A.I. Evdokimov Moscow State University of Medicine and Dentistry; Professor, Chair of Clinical Pharmacology and Propaedeutics of Internal Medicine, Sechenov University.

Delegatskaya ul. 20-1, Moscow, 127473; Bolshaya Pirogovskaya ul. 2-4, Moscow, 119435.


M. S. Cherniaeva
Central State Medical Academy of Administrative Department of the President of the Russian Federation
Russian Federation

Marina  S. Cherniaeva – MD, PhD, Associate Professor, Chair of Internal Medicine and Preventive Medicine.

Marshala Timoshenko ul. 19-1A, Moscow, 121359.


M. M. Petrova
Krasnoyarsk State Medical University named after Prof. V.F. Voino-Yasenetsky
Russian Federation

Marina  M. Petrova – MD, PhD, Professor, Chair of Polyclinic Therapy, Family Medicine and Healthy Lifestyle with a Course of Postgraduate Education.

Partizana Zheleznyaka ul. 1, Krasnoyarsk, 660022.


O. V. Golovina
Russian Medical Academy of Continuous Professional Education
Russian Federation

Olga V. Golovina – MD, PhD, Associate Professor, Chair of Clinical Pharmacology and Therapy.

Barrikadnaya ul. 2/1-1, Moscow, 125993.



1. Freeman R., Wieling W., Axelrod F.B. et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21(2):69-72. doi:10.1007/s10286-011-0119-5.

2. Bradbury S., Eggleston C. Postural hypotension: report of three cases. Am Heart J (St. Louis). 1925;1:73-86.

3. Brignole M., Moya A., de Lange F.J. et al. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;39(21):1883-948. doi:10.1093/eurheartj/ehy037.

4. Grubb B.P. Pathophysiology and differential diagnosis of neurocardiogenic syncope. Am J Cardiol. 1999;84(8А):3Q-9Q.

5. Golovina G.A., Duplyakov D.V. Orthostatic hypotension: The cardiologist’s view. Arterial'naya Gipertoniya. 2014;20(2):75-85. (In Russ.).

6. Ricci F., De Caterina R., Fedorowski A. Orthostatic Hypotension: Epidemiology, Prognosis, and Treatment. J Am Coll Cardiol. 2015;66(7):848-60. doi:10.1016/j.jacc.2015.06.1084.

7. Shannon J.R., Diedrich A., Biaggioni I. et al. Water drinking as a treatment for orthostatic syndromes. Am J Med. 2002;112(5):355-60.

8. Sutton R. Clinical classification of syncope. Prog Cardiovasc Dis. 2013;55(4):339-44. doi:10.1016/j.pcad.2012.11.005.

9. Thompson W.O., Thompson P.K., Dailey M.E. The effect of posture upon the composition and volume of the blood in man. Proc Natl Acad Sci U S A. 1928;14(1):94-8.

10. Grubb B.P., Karas B. Clinical disorders of the autonomic nervous system associated with orthostatic intolerance: an overview of classification, clinical evaluation, and management. Pacing Clin Electrophysiol. 1999;22(5):798-810.

11. Hainsworth R. Vascular capacitance: its control and importance. Rev Physiol Biochem Pharmacol. 1986;105:101-73.

12. Robertson D. Mechanisms of orthostatic hypotension. Curr Cardiol. 1993;8:737-45.

13. Atakhanov Sh.E., Robertson D. Orthostatic hypotension and autonomic dysfunction (mechanisms and classification). Kardiologiia. 1995;3:41-9. (In Russ.).

14. Mader S.L. Postprandial hypotension in the elderly. J Am Geriatr Soc. 1988;36(1):84.

15. Robertson D., Wade D., Robertson R.M. Postprandial alterations in cardiovascular hemodynamics in autonomic dysfunctional states. Am J Cardiol. 1981;48(6):1048-52.

16. Krediet C.T., Go-Schon I.K., Kim Y.S. et al. Management of initial orthostatic hypotension: Lower body muscle tensing attenuates the transient arterial blood pressure decrease upon standing from squatting. Clin Sci (London). 2007;113(10):401-7. doi:10.1042/CS20070064.

17. Jordan J., Shannon J.R., Black B.K. et al. The pressor response to water drinking in humans: a sympathetic reflex? Circulation. 2000;101(5):504-9.

18. Masuo K., Mikami H., Ogihara T., Tuck M.L. Changes in frequency of orthostatic hypotension in elderly hypertensive patients under medications. Am J Hypertens. 1996;9(3):263-8.

19. Lagi A., Rossi A., Cornelli A. et al. Postural hypotension in hypertensive patients. Blood Press. 2003;12(5-6):340-4.

20. Mader S.L. Orthostatic hypotension. Med Clin North Am. 1989;73(6):1337-49.

21. Gupta V., Lipsitz L.A. Orthostatic hypotension in the elderly: diagnosis and treatment. Am J Med. 2007;120(10):841-7. doi: 10.1016/j.amjmed.2007.02.023.

22. Goldstein D.S., Robertson D., Esler M. et al. Dysautonomias: clinical disorders of the autonomic nervous system. Ann Intern Med. 2002;137(9):753-63.

23. Kanjwal K., George A., Figueredo V.M. et al. Orthostatic hypotension: definition, diagnosis and management. J Cardiovasc Med (Hagerstown) 2015;16(2):75-81. doi:10.2459/01.JCM.0000446386.01100.3.

24. Fedorowski A., Melander O. Syndromes of orthostatic intolerance: a hidden danger. J Intern Med. 2013;273(4):322-35. doi: 10.1111/joim.12021.

25. Robertson D. The pathophysiology and diagnosis of orthostatic hypotension. Clin Auton Res. 2008;18 Suppl 1:2-7. doi: 10.1007/s10286-007-1004-0.

26. Goldstein D.S., Sharabi Y. Neurogenic orthostatic hypotension: a pathophysiological approach. Circulation. 2009;119(1):139-46. doi: 10.1161/CIRCULATIONAHA.108.805887.

27. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure and multiple system atrophy. J Neurol Sci. 1996;144(1-2):218-9.

28. Lipsitz L.A. Aging and the autonomous nervous system. In: Robertson D., Low P.A., Polinski R.J., eds. Primer on the Autonomic Nervous System. San Diego: Academic Press; 1996. pp. 79-83.

29. Rutan G.H., Hermanson B., Bild D.E. et al. Orthostatic hypotension in older adults: the cardiovascular health study. Hypertension. 1992;19(6 Pt 1):508-19.

30. Strogatz D.S., Keenan N.L., Barnett E.M., Wagner E.H. Correlates of postural hypotension in a community sample of elderly blacks and whites. J Am Geriatr Soc. 1991;39(6):562-6.

31. Shin C., Abbott R.D., Lee H. et al. Prevalence and correlates of orthostatic hypotension in middleaged men and women in Korea: the Korean Health and Genome Study. J Hum Hypertens. 2004;18(10):717-23. doi:10.1038/sj.jhh.1001732.

32. Fedorowski A., Burri P., Melander O. Orthostatic hypotension in genetically related hypertensive and normotensive individuals. J Hypertens. 2009;27(5):976-82.

33. Räihä I., Luutonen S., Piha J. et al. Prevalence, predisposing factors, and prognostic importance of postural hypotension. Arch Intern Med. 1995;155(9):930-5.

34. Lagro J., Laurenssen N.C., Schalk B.W. et al. Diastolic blood pressure drop after standing as a clinical sign for increased mortality in older falls clinic patients. J Hypertens. 2012;30(6):1195-202. doi:10.1097/HJH.0b013e328352b9fd.

35. Poon I.O., Braun U. High prevalence of orthostatic hypotension and its correlation with potentially causative medications among elderly veterans. J Clin Pharm Ther. 2005;30(2):173-8. doi:10.1111/j.1365-2710.2005.00629.x.

36. Fedorowski A., Engstrom G., Hedblad B., Melander O. Orthostatic hypotension predicts incidence of heart failure: the Malmö Preventive Project. Am J Hypertens. 2010;23(11):1209-15. doi:10.1038/ajh.2010.150

37. Krolewski A.S., Warram J.H., Cupples A. et al. Hypertension, orthostatic hypotension and the microvascular complications of diabetes. J Chronic Dis. 1985;38(4):319-26.

38. Sasaki O., Nakahama H., Nakamura S. et al. Orthostatic hypotension at the introductory phase of haemodialysis predicts all-cause mortality. Nephrol Dial Transplant. 2005;20(2):377-81. doi:10.1093/ndt/gfh614.

39. Masaki K.H., Schatz I.J., Burchfiel C.M. et al. Orthostatic hypotension predicts mortality in elderly men: the Honolulu Heart Program. Circulation. 1998;98(21):2290-5.

40. Verwoert G.C., Mattace-Raso F.U., Hofman A. et al. Orthostatic hypotension and risk of cardiovascular disease in elderly people: the Rotterdam study. J Am Geriatr Soc. 2008;56(10):1816-20. doi:10.1111/j.1532-5415.2008.01946.x.

41. Eigenbrodt M.L., Rose K.M., Couper D.J. et al. Orthostatic hypotension as a risk factor for stroke: the Atherosclerosis Risk in Communities (ARIC) study, 1987-1996. Stroke. 2000;31(10):2307-13.

42. Weiss A., Beloosesky Y., Kornowski R. et al. Influence of orthostatic hypotension on mortality among patients discharged from an acute geriatric ward. J Gen Intern Med. 2006;21(6):602-6. doi:10.1111/j.1525-1497.2006.00450.x.

43. Hossain M., Ooi W.L., Lipsitz L.A. Intra-individual postural blood pressure variability and stroke in elderly nursing home residents. J Clin Epidemiol. 2001;54(5):488-94.

44. Ricci F., Fedorowski A. Cardiovascular morbidity and mortality related to orthostatic hypotension: a meta-analysis of prospective observational studies. Eur Heart J. 2015;36:1609-17. doi:10.1093/eurheartj/ehv093.

45. Fedorowski A., Hedblad B., Melander O. Early postural blood pressure response and cause-specific mortality among middle-aged adults. Eur J Epidemiol. 2011;26(7):537-46. doi:10.1007/s10654-011-9578-1.

46. Fedorowski A., Wahlstrand B., Hedner T., Melander O. Systolic and diastolic component of orthostatic hypotension and cardiovascular events in hypertensive patients: the Captopril Prevention Project. J Hypertens. 2014;32(1):75-81. doi:10.1097/HJH.0b013e328365cd59.

47. Rosamond W.D., Folsom A.R., Chambless L.E. et al. Stroke incidence and survival among middleaged adults: 9-year follow-up of the Atherosclerosis Risk in Communities (ARIC) cohort. Stroke. 1999;30(4):736-43.

48. Rose K.M., Eigenbrodt M.L., Biga R.L. et al. Orthostatic hypotension predicts mortality in middleaged adults: the Atherosclerosis Risk in Communities (ARIC) study. Circulation 2006;114(7):630-6. doi: 10,1161/CIRCULATIONAHA.105.598722.

49. Manolio T.A., Kronmal R.A., Burke G.L. et al. Short-term predictors of incident stroke in older adults. The Cardiovascular Health Study. Stroke 1996;27(9):1479-86.

50. 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(4):383-9. doi:10.1111/j.1365-2796.2010.02261.x.

51. Fedorowski A., Burri P., Struck J. et al. Novel cardiovascular biomarkers in unexplained syncopal attacks: the SYSTEMA cohort. J Intern Med. 2013;273(4):359-67. doi:10.1111/joim.12043.

52. Franceschini N., Rose K.M., Astor B.C. et al. Orthostatic hypotension is associated with incident chronic kidney disease: The Atherosclerosis Risk In Communities Study. Hypertension. 2010;56(6):1054-9. doi:10.1161/HYPERTENSIONAHA.110.156380.

53. Fleg J.L., Evans G.W., Margolis K.L. et al. Orthostatic Hypotension in the ACCORD Blood Pressure Trial: Prevalence, Incidence, and Prognostic Significance. Hypertension. 2016;68(4):888-95. doi:10.1161/HYPERTENSIONAHA.116.07474.

54. van Hateren K.J., Kleefstra N., Blanker M.H. et al. Orthostatic hypotension, diabetes, and falling in older patients: a cross-sectional study. Br J Gen Pract. 2012;62(603):e696-702. doi:10.3399/bjgp12X656838.

55. 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(11):2169-73.

56. Shi J., Yang S.H., Stubley L. et al. Hypoperfusion induces overexpression of beta-amyloid precursor protein mRNA in a focal ischemic rodent model. Brain Res. 2000;853(1):1-4.

57. Punchick B., Freud T., Press Y. The association between orthostatic hypotension and cognitive state among adults 65 years and older who underwent a comprehensive geriatric assessment. Medicine. 2016;95(29):e4264. doi:10.1097/MD.0000000000004264.

58. 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(3):383-9. doi:10.1111/j.1532-5415.2011.03317.x.

59. Cooke J., Carew S., Quinn C. et al. The prevalence and pathological correlates of orthostatic hypotension and its subtypes when measured using beat-to-beat technology in a sample of older adults living in the community. Age Ageing. 2013;42(6):709-14. doi:10.1093/ageing/aft112.

60. Hiitola P., Enlund H., Kettunen R. et al. Postural changes in blood pressure and the prevalence of orthostatic hypotension among homedwelling elderly aged 75 years or older. J Human Hypertens. 2009;23(1):33-9. doi:10.1038/jhh.2008.81.

61. Rose K.M., Couper D., Eigenbrodt M.L. et al. Orthostatic hypotension and cognitive function: the Atherosclerosis Risk in Communities Study. Neuroepidemiology. 2010;34(1):1-7. doi:10.1159/000255459.

62. Viramo P., Luukinen H., Koski K. et al. Orthostatic hypotension and cognitive decline in older people. J Am Geriatr Soc. 1999;47(5):600-4.

63. Yap P.L., Niti M., Yap K.B. et al. Orthostatic hypotension, hypotension and cognitive status: early comorbid markers of primary dementia? Dement Geriatr Cogn Disord. 2008;26(3):239-46. doi:10.1159/000160955.

64. Aung A.K., Corcoran S.J., 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(1):35-41.

65. Boddaert J., Tamim H., Verny M., Belmin J. Arterial stiffness is associated with orthostatic hypotension in elderly subjects with history of falls. J Am Geriatr Soc. 2004;52(4):568-72. doi:10.1111/j.1532-5415.2004.52163.x.

66. Shen S., He T., Chu J. et al. Uncontrolled hypertension and orthostatic hypotension in relation to standing balance in elderly hypertensive patients. Clin Interv Aging. 2015;10:897-906. doi:10.2147/CIA.S81283.

67. Gaxatte C., Faraj E., Lathuillerie O. et al. Alcohol and psychotropic drugs: risk factors for orthostatic hypotension in elderly fallers. J Hum Hypertens. 2017;31(4):299-304. doi:10.1038/jhh.2013.82.

68. Schoon Y., Lagro J., Verhoeven Y. et al. Hypotensive syndromes are not associated with cognitive impairment in geriatric patients. Am J Alzheimer’s Dis Other Demen. 2013;28(1):47-53. doi:10.1177/1533317512466692.

69. Allan L.M., Ballard C.G., Allen J. et al. Autonomic dysfunction in dementia. J Neurol Neurosurg Psychiatry. 2007;78(7):671-7. doi:10.1136/jnnp.2006.102343.

70. Elmstahl S., Widerstrom E. Orthostatic intolerance predicts mild cognitive impairment: incidence of mild cognitive impairment and dementia from the Swedish general population cohort Good Aging in Skane. Clin Interv Aging. 2014;9:1993-2002. doi:10.2147/CIA.S72316.

71. Peralta C., Stampfer-Kountchev M., Karner E. et al. Orthostatic hypotension and attention in Parkinson’s disease with and without dementia. J Neural Transm (Vienna). 2007;114(5):585-8. doi:10.1007/s00702-006-0615-2.

72. Sonnesyn H., Nilsen D.W., Rongve A. et al. High prevalence of orthostatic hypotension in mild dementia. Dement Geriatr Cogn Disord. 2009;28(4):307-13. doi:10.1159/000247586.

73. Mehrabian S., Duron E., Labouree F. et al. Relationship between orthostatic hypotension and cognitive impairment in the elderly. J Neurol Sci. 2010;299(1-2):45-8. doi:10.1016/j.jns.2010.08.056.

74. Bengtsson-Lindberg M., Larsson V., Minthon L. et al. Lack of orthostatic symptoms in dementia patients with orthostatic hypotension. Clin Auton Res. 2015;25(2):87-94. doi:10.1007/s10286-014-0244-z.

75. Frewen J., Finucane C., Savva G.M. et al. Orthostatic hypotension is associated with lower cognitive performance in adults aged 50 plus with supine hypertension. J Gerontol A Biol Sci Med Sci. 2014;69(7):878-85. doi:10.1093/gerona/glt171.

76. Wolters F.J., Mattace-Raso F.U., Koudstaal P.J. et al. Orthostatic Hypotension and the Long-Term Risk of Dementia: A Population-Based Study. PLOS Med. 2016;13(10):e1002143. doi:10.1371/journal.pmed.1002143.

77. Gibbons C.H., Schmidt P., Biaggioni I. et al. The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension. J Neurol. 2017;264(8):1567-82. doi:10.1007/s00415-016-8375-x.

78. Low P.A. Neurogenic orthostatic hypotension: pathophysiology and diagnosis. Am J Manag Care. 2015;21(13 Suppl):s248-57.

79. Biaggioni I. Treatment: special conditions: orthostatic hypotension. J Am Soc Hypertens. 2015;9(1):67-9. doi:10.1016/j.jash.2014.12.005.

80. White N.J. Heart-rate changes on standing in elderly patients with orthostatic hypotension. Clin Sci (London). 1980;58(5):411-3.

81. Ryazanceva E.E., Melekhov A.V., Gendlin G.E. Artery hypertension and orthostatic hypotension: clinic dilemma. Atmosfera. Antigipertenzivnaya Terapiya. 2014;2:20-7. (In Russ.).

For citation:

Ostroumova O.D., Cherniaeva M.S., Petrova M.M., Golovina O.V. Orthostatic Hypotension: Definition, Pathophysiology, Classification, Prognostic Aspects, Diagnostics and Treatment. Rational Pharmacotherapy in Cardiology. 2018;14(5):747-756. (In Russ.)

Views: 152

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.

ISSN 1819-6446 (Print)
ISSN 2225-3653 (Online)