Symptoms are an optimal target for orthostatic hypotension screening and management: an argument in favor

Orthostatic hypotension (OH), defined as a sustained reduction of ≥ 20 mmHg in systolic or ≥ 10 mmHg in diastolic blood pressure within 3 minutes of standing, represents one of the most clinically significant manifestations of autonomic failure. Beyond its hemodynamic definition, OH is associated with disabling symptoms, falls, syncope, reduced quality of life, increased healthcare utilization, and excess mortality. In clinical practice, management often requires balancing objective blood pressure measurements with the patient's lived experience of orthostatic intolerance. This viewpoint argues that symptoms represent an appropriate and clinically meaningful target for screening and management of OH. Three central assumptions support this perspective. First, patients are reliable reporters of orthostatic symptoms and clinicians are capable interpreters of these reports. Validated patient-reported outcome measures, such as the Orthostatic Hypotension Questionnaire (OHQ), demonstrate that symptom burden and functional impairment can be reproducibly quantified and that clinically meaningful changes can be detected. Second, although the relationship between orthostatic blood pressure changes and symptoms is not absolute, evidence supports a clinically relevant association, with symptomatic individuals often experiencing greater cerebral hypoperfusion when upright. Third, symptoms serve as a practical proxy for meaningful OH-related outcomes, including functional independence, fall risk, and quality of life, and have been accepted as primary endpoints in pivotal clinical trials. A symptom-centered framework complements objective hemodynamic assessment by contextualizing physiological findings within patients' functional experience. Integrating symptom reporting with orthostatic measurements provides a pragmatic, patient-centered approach to screening, treatment decisions, and evaluation of therapeutic response in OH.