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Autonomics and Orthostatic Hypotension

Leonard Chiu


  • Orthostatic Hypotension: SBP ↓ > 20 mmHg, DBP ↓ > 10 mmHg), or HR Increase > 30 within 3 min of standing up or head-up tilt to 60% on a tilt table
  • Etiologies: Neurogenic OH (nOH) vs non-neurogenic OH
  • nOH associated with autonomic failure
    • Blunted tachycardia during hypotension characteristic of autonomic failure
    • nOH: If HR rise is \<15
    • nOH also associated with periods of high BP (supine hypertension)
    • Ex: Neurodegenerative disease, neuropathy (diabetes, amyloid, paraneoplastic, etc)
  • Other causes: volume depletion (most common), medications (diuretics, alpha-1 blockers, BB, etc), pump failure (severe AS, arrhythmia)


  • Orthostatic vitals signs (checking supine, sitting, and standing with 5-minute wait in each position)
  • Volume status exam
  • Labs: CBC, CMP, EKG, TSH, B12, , LFTs,
  • Consider SPEP/UPEP, paraneoplastic panel, autonomic function testing depending on clinical context
  • Autonomic Function Testing: Available at 4:15pm Tues, Wed, Thurs NPO 4 hours prior
  • Hold oral pressors and antihypertensives 12 hours prior


  • Conservative:
  • TED hose and abdominal binder for ambulation
  • Drink 16oz of fluid 15 min prior to standing
  • If they have supine HTN, keep HOB 30-45 degrees at all times
  • Add 2.3-4.6g of salt per day to diet (if no contraindications)
  • Avoid high temperatures (which cause peripheral vasodilation)
  • Supine HTN therapies: transdermal nitroglycerin (preferred); minoxidil, hydralazine, or clonidine in select patients

Orthostatic hypotension pharmacologic therapies

Drug Dose Mechanism Side effects
Fludocortisone (Florinef)

0.1mg QD

↑ by 0.1 mg

Max: 0.3 mg QD

Mineralocorticoid increase blood volume. Enhances sensitivity to circulating catecholamines




Do not use in CHF


2.5mg TID

↑ by 2.5mg

Up to 10mg TID

Peripheral-selective α1 agonist → constricts both aa & vv

Supine HTN

Pilomotor reactions


GI upset

Avoid in uncontrolled HTN, urinary retention, heart disease



↑ by 100mg

Up to 600mg TID

NE precursor → carboxylated to NE. Can cross BBB. Supine HTN, less than midodrine
Atomoxetine 10mg or 18mg SNRI Do not use w/ glaucoma or MAOI

Last update: 2022-05-29 04:29:03