Prevalence of orthostatic hypotension in heart failure: a systematic review and meta-analysis

Background Orthostatic hypotension (OH), defined as a reduction in systolic/diastolic blood pressure ≥20/10 mmHg upon standing, is common in older adults and may interfere with the optimization of guideline-directed medical therapy (GDMT) for Heart Failure (HF). However, the prevalence of OH in patients with HF has not been systematically quantified. Aims To estimate the prevalence of orthostatic hypotension among patients with heart failure through a systematic review and meta-analysis. Methods This study was conducted according to PRISMA guidelines and registered in PROSPERO (CRD42023420255). MEDLINE and EMBASE databases were systematically searched from inception to 31 December 2025. Studies reporting the prevalence of OH in HF populations with a sample size ≥100 patients were included. Pooled prevalence estimates with 95% confidence intervals (CI) were calculated, and heterogeneity was assessed using the I² statistic. Subgroup analyses were performed according to geographical location, study design, and clinical setting. Results Nine studies (10 cohorts) including 2036 patients with HF were analyzed. The pooled prevalence of OH was 26.7% (95% CI 20.4–34.2%), indicating that approximately one in four HF patients presents this condition. Between-study heterogeneity was high (I²=90.2%). Subgroup analyses revealed higher prevalence in Europe and Asia and the Middle East compared with other countries. Conclusions HF is often burdened by OH which is common and found in 1 out 4 patients with HF and may complicate its management. Its impact on GDMT and clinical outcomes needs to be further investigated.