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.
Key red flags
Exertional or supine syncope, chest pain, abrupt dyspnoea, persistent palpitations, melaena/haematemesis, focal neurology, sepsis features or family history of sudden death.
Investigation priorities
Demonstrate the haemodynamic change and relate it to symptoms.
Management branches
Dizziness, presyncope, syncope or unexplained falls related to posture.
- First: assess ABCs, injury, bleeding, infection, neurological deficit and cardiac red flags; use the urgent pathway if present.
- Next: record lying or seated BP/pulse and repeat after standing for at least 1 minute, documenting symptoms and considering a 3-minute reading.
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.
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.