Practice Rational Testing

Postural hypotension

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3128 (Published 16 June 2011) Cite this as: BMJ 2011;342:d3128
  1. T Sathyapalan, senior lecturer1,
  2. M M Aye, clinical research fellow1,
  3. S L Atkin, professor 1
  1. 1Academic Endocrinology, Diabetes and Metabolism, Hull-York Medical School, Hull Royal Infirmary, Hull HU3 2RW, UK
  1. Correspondence to: Professor Stephen L Atkin, Head of Academic Endocrinology, Diabetes and Metabolism, Hull York Medical School, Michael White Diabetes Centre, Hull, HU3 2RW Stephen.Atkin{at}hyms.ac.uk

Postural hypotension can have various causes, and investigations include history taking, physical examination, and laboratory testing

Learning points

  • Postural hypotension is an abnormal fall in blood pressure—of at least 20 mm Hg systolic and 10 mm Hg diastolic—within three minutes of standing upright

  • The commonest causes of postural hypotension are medications and conditions that cause hypovolaemia

  • The patient’s history is of particular importance and has a high diagnostic value

  • Even after extensive evaluation, about a third of patients with persistent, consistent postural hypotension have no identified cause

A 70 year old man presents with recurrent lightheadedness for two to three weeks when getting up at night to pass urine over. On questioning, he reports having occasional episodes of lightheadedness when standing for prolonged periods. Three months previously he had been started on the α adrenergic blocker alfuzosin 2.5 mg three times daily, after complaining of urinary frequency and a poor urinary stream; physical examination had found an enlarged prostate along with a value for prostate specific antigen within the normal range. His other medical history includes well controlled type 2 diabetes, for which he is taking metformin 500 mg three times daily and simvastatin 40 mg daily.

On physical examination, his blood pressure was 130/80 mm Hg (right arm supine) and 105/69 mm Hg (right arm standing) with the patient complaining of lightheadedness after standing up. His heart rate was a regular 88 beats/min supine and did not rise with standing. Physical examination was otherwise unremarkable.

Postural (also known as orthostatic) hypotension is an abnormal decrease in blood pressure—of at least 20 mm Hg systolic and 10 mm Hg diastolic—within three minutes of standing upright.1 The prevalence of postural hypotension increases with age,2 and among elderly people it ranges from 6% (in those who are healthy)3 to 68% (in …

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