Abstract / Summary
Background and Objectives: Hypertension, atrial fibrillation (AF), and orthostatic hypotension (OH) are common in older adults and may coexist. Their coexistence challenges blood pressure (BP) assessment and treatment decisions because AF reduces measurement reproducibility, OH introduces posture-dependent BP changes, and therapies for hypertension or AF may affect orthostatic tolerance. This review examines evidence relevant to BP assessment and treatment decisions in this setting. Materials and Methods: A focused narrative review was conducted using targeted PubMed searches, supplemented by contemporary cardiovascular guidelines, scientific statements, consensus documents, systematic reviews, meta-analyses, and original studies. Results: Hypertension frequently coexists with OH in older adults, while AF adds marked beat-to-beat BP variability and reduces the reproducibility of BP readings. Orthostatic assessment identifies clinically relevant BP falls not captured by seated BP alone. Across hypertension trials, baseline OH did not appear to diminish the cardiovascular benefit of BP lowering, although frail older adults and patients with symptomatic, severe, or neurogenic OH were underrepresented. Effects on orthostatic tolerance differ by drug class and mechanism. β-blockers may blunt compensatory heart-rate responses but may still be required for AF rate control. Frailty and falls influence treatment tolerance and bleeding risk, while the fall risk alone does not generally justify withholding indicated anticoagulation. Conclusions: In older adults with hypertension, AF, and OH, treatment decisions should be guided by BP assessment that captures rhythm-related measurement variability and postural BP change. OH should prompt reassessment of the BP profile, symptoms, and contributing medications rather than automatic antihypertensive deintensification. Medication review should distinguish reversible contributors to orthostatic intolerance from therapies with compelling cardiovascular indications, while frailty, falls, and anticoagulation should inform risk–benefit assessment. Prospective studies are needed to establish how BP and hypertension can be reliably assessed in older adults with coexisting AF and OH and how such assessment should guide treatment.