Practitioners’ views on the measurement and management of postural hypotension in general practice: a qualitative inquiry

Rosina Cross; Sinéad TJ McDonagh; Bethan Treadgold; Jane Masoli; Judit Konya; Gary Abel; James P Sheppard; Bethany Jakubowski; Cini Bhanu; Jayne Fordham; Sarah Lamb; Katrina Turner; Rupert A Payne; Richard McManus; John Campbell; Christopher E Clark

doi:10.3399/BJGP.2024.0695

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Testing patients for orthostatic hypotension in less than a minute is better than not testing at all
Stephen Katona

Published on: 17 October 2025

Published on: (17 October 2025)
Page navigation anchor for Testing patients for orthostatic hypotension in less than a minute is better than not testing at all
Testing patients for orthostatic hypotension in less than a minute is better than not testing at all
Stephen Katona, Out of hours GP, GTD Healthcare, New Century House, Progress Way, Denton, Manchester, M34 2GP
Cross et al identified many clinicians don’t feel they have time to detect orthostatic hypotension (OH).¹ 67% took measurements within a minute of standing. This is in keeping with advice given by Juraschek et al who found readings taken this soon correlate best with long term adverse outcomes.² The finding that many clinicians prefer to focus on a fall in systolic blood pressure (SBP)¹is also hard to criticise as there doesn’t appear to be much data about the prognostic significance of postural changes in diastolic blood pressure without an accompanying fall in SBP.

Cross et al also mention many clinicians do not allow their patients a prolonged sitting period before standing. Although this period might allow a patient’s heart rate (HR) to settle, are we sure it is needed? If, instead, we paid attention to changes in a patient’s heart rate (HR) we might simply be able to ignore a fall in SBP when there is also a similar percentage fall in HR. Conversely, no study has ever looked at whether OH carries a worse prognosis when accompanied by orthostatic tachycardia.

One way to assess postural changes in both SBP and HR is to use the formula (SBP resting/ SBP standing) x (HR standing/ HR resting). Michael Witting, a professor of emergency medicine, first came up with it in 2003 as a means to detect hypovolaemia and called it Ratio of Orthostatic Shock Indices (ROSI).

Unlike most...
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Cross et al identified many clinicians don’t feel they have time to detect orthostatic hypotension (OH).¹ 67% took measurements within a minute of standing. This is in keeping with advice given by Juraschek et al who found readings taken this soon correlate best with long term adverse outcomes.² The finding that many clinicians prefer to focus on a fall in systolic blood pressure (SBP)¹is also hard to criticise as there doesn’t appear to be much data about the prognostic significance of postural changes in diastolic blood pressure without an accompanying fall in SBP.

Cross et al also mention many clinicians do not allow their patients a prolonged sitting period before standing. Although this period might allow a patient’s heart rate (HR) to settle, are we sure it is needed? If, instead, we paid attention to changes in a patient’s heart rate (HR) we might simply be able to ignore a fall in SBP when there is also a similar percentage fall in HR. Conversely, no study has ever looked at whether OH carries a worse prognosis when accompanied by orthostatic tachycardia.

One way to assess postural changes in both SBP and HR is to use the formula (SBP resting/ SBP standing) x (HR standing/ HR resting). Michael Witting, a professor of emergency medicine, first came up with it in 2003 as a means to detect hypovolaemia and called it Ratio of Orthostatic Shock Indices (ROSI).

Unlike most OH diagnosed in the community, Juraschek et al found 69.2% of hospital diagnosed OH could be explained by potentially reversible conditions such as hypovolaemia and cardiovascular disease.⁴ One explanation might be that community clinicians prefer not to make a diagnosis of OH in patients who are acutely unwell. However, this might change if guidelines stated their patients didn’t have to stand for so long, and allow potential causes of shock, such as sepsis, to be detected at an earlier stage.⁵

References

1. Cross R, McDonagh ST, Treadgold B et al. Practitioners' views on the measurement and management of postural hypotension in general practice: a qualitative inquiry. Br J Gen Pract 2025 Sep 22:BJGP.2024.0695. doi: 10.3399/BJGP.2024.0695. Epub ahead of print.

2. Juraschek SP, Daya N, Rawlings AM et al. Association of History of Dizziness and Long-term Adverse Outcomes With Early vs Later Orthostatic Hypotension Assessment Times in Middle-aged Adults. JAMA Intern Med 2017; 77(9):1316-1323. doi: 10.1001/jamainternmed.2017.2937.

3. Witting MD, Gallagher K. Unique cutpoints for sitting-to-standing orthostatic vital signs. Am J Emerg Med 2003; 21(1):45-7. doi: 10.1053/ajem.2003.50009.

4. Wagner BA, Rose E, Strauss AC, Khan S, Anderson TS, Juraschek SP. Characteristics, Management, and Outcomes of Hospitalized Patients with Orthostatic Hypotension. J Clin Hypertens (Greenwich) 2025; 27(8):e70118. doi: 10.1111/jch.70118.

5. Katona SJ. Changes in posture may help NEWS2 detect sepsis. Br J Gen Pract 2023 Nov 11. https://bjgp.org/content/changes-posture-may-help-news2-detect-sepsis.
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Competing Interests: None declared.

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