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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Postural hypotension

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Escalate

Do not attribute collapse to postural hypotension when there is exertional syncope, chest pain, new breathlessness, sustained palpitations, focal neurology, major bleeding, persistent hypotension or serious injury. These features need urgent assessment for cardiac, neurological, haemorrhagic or septic causes.

Synopsis

Confirm a reproducible orthostatic BP fall, identify reversible causes and use staged non-drug and drug treatment without provoking supine hypertension.

  • In a person with postural dizziness or falls, measure BP lying or seated and again after standing for at least 1 minute.
  • A fall of at least 20 mmHg systolic or 10 mmHg diastolic supports postural hypotension; symptoms can still be important when the threshold is not captured once.
  • Record heart-rate response and symptoms with the BP: a blunted pulse rise suggests autonomic failure, whereas marked tachycardia suggests volume loss or another orthostatic syndrome.
  • First address dehydration, blood loss, infection, deconditioning and contributory medicines such as antihypertensives, diuretics, nitrates, alpha-blockers and psychoactive drugs.
  • For coexisting hypertension, NICE advises basing the treatment target on standing BP when there is a significant postural fall or postural symptoms.
  • Individualised fluids, salt where safe, gradual position change, physical counter-pressure manoeuvres and abdominal or waist-high compression are core measures.
  • Midodrine is licensed for severe orthostatic hypotension due to autonomic dysfunction after correctable factors have been excluded; avoid dosing near bedtime.
  • Every pressor strategy can worsen supine hypertension, urinary retention or fluid overload, so benefit must be demonstrated with standing function as well as BP readings.

Key red flags

Alternative dangerous cause

Exertional or supine syncope, chest pain, abrupt dyspnoea, persistent palpitations, melaena/haematemesis, focal neurology, sepsis features or family history of sudden death.

Investigation priorities

01
Lying-to-standing BP and pulseFirst step

Demonstrate the haemodynamic change and relate it to symptoms.

Management branches

confirmSymptoms on standing

Dizziness, presyncope, syncope or unexplained falls related to posture.

  1. First: assess ABCs, injury, bleeding, infection, neurological deficit and cardiac red flags; use the urgent pathway if present.
  2. Next: record lying or seated BP/pulse and repeat after standing for at least 1 minute, documenting symptoms and considering a 3-minute reading.
  3. Next: obtain an ECG and targeted blood tests, then review volume status, meals, alcohol and every prescribed/non-prescribed medicine.
  4. Escalation: recurrent unexplained syncope, abnormal ECG, severe persistent hypotension or a possible autonomic disorder needs specialist assessment.

Key medicines

Midodrine2.5 mg orally three times daily initially during waking hours; increase at weekly intervals according to response up to 10 mg three times daily. Take the final dose at least 4 hours before bedtime.Monitor lying and standing BP. Stop/review for severe supine hypertension, bradycardia or urinary retention. Contraindications include severe organic heart disease (including aortic aneurysm), hypertension, acute kidney disease or CrCl <30 mL/min, serious obliterative vascular disease, serious prostate disorder/urinary retention, phaeochromocytoma, hyperthyroidism and narrow-angle glaucoma; check the current SmPC for the full list and interactions.
Fludrocortisone (off-label)100 micrograms orally once daily is the adult regimen used in the placebo-controlled evidence summarised by NICE; any titration should be specialist-directed.Unlicensed for postural hypotension in the UK, and NICE found the evidence base limited. Can cause supine hypertension, oedema, heart-failure decompensation, hypokalaemia and headache; monitor BP, weight, electrolytes and renal function and avoid or use extreme caution in heart failure/CKD.
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Sources and review status3 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG136: Hypertension in adults—postural hypotensionMeasurement threshold and use of standing BP for treatment targets.
  • NICE ESUOM20: Postural hypotension in adults—fludrocortisoneEvidence limitations, off-label status and safety monitoring.
  • eMC: Midodrine 2.5 mg tablets SmPCLicensed indication, dose, timing, contraindications and monitoring.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom