Personalised physiological medicine: Orthostatic hypotension

Orthostatic hypotension (OH) is a very common and debilitating condition, characterised by a significant drop in blood pressure (BP) on standing upright. Multiple neuro-cardiovascular mechanisms should stabilise BP when moving to an upright position but in OH, BP decline results from dysfunction of neuro-cardiovascular mechanisms. With the advent of non-invasive, beat-to-beat BP measurement, the detailed postural BP profile presents an opportunity to explore the underlying pathological deficits seen in OH. To date, several distinct clusters of postural BP drop have been identified, typically defined by the rate and duration of BP decline and the degree of recovery. The morphology of the BP drop may reflect the underlying cardiac output and peripheral vascular resistance. There are three principal treatment strategies for OH; conservative management, fludrocortisone or midodrine. As each of these therapies have different therapeutic mechanisms, in this review we hypothesise how they could be used in a more targeted manner to treat the underlying physiological deficit - conservative management for ‘initial drop, quick recovery’, fludrocortisone for ‘medium drop, slow recovery/venular-deficit’ and midodrine for ‘large drop, non-recovery/arteriolar-deficit’.