A lying and standing blood pressure taken badly is worse than none, because it produces a normal number that closes the question. Most are taken badly.
Lie the patient flat for five minutes - not sitting, and not for one minute while you write. Take the supine reading. Then stand them, and measure at one minute and at three minutes, keeping the cuff at heart level and the arm supported. Ask about symptoms at each reading and write those down alongside the numbers; a patient who greys out at 30 seconds and recovers by three minutes has orthostatic hypotension whatever the three-minute figure says. A fall of 20 mmHg systolic or 10 mmHg diastolic is the threshold, and in a patient with supine hypertension a smaller fall can still be symptomatic.
Then do the thing the measurement is for: look at the drug chart. Antihypertensives, alpha blockers, nitrates, diuretics, antidepressants, antipsychotics and anticholinergics all contribute, and the anticholinergic burden in particular tends to accumulate unseen across several prescribers.
- Five minutes supine before the first reading, not one minute sitting.
- Measure at one minute and three minutes standing, arm supported at heart level.
- Record symptoms at each timepoint, not only the numbers.
- Use a fall of 20 mmHg systolic or 10 mmHg diastolic, and treat symptoms as significant below that.
- Review the whole drug chart afterwards, including anticholinergic burden across prescribers.
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