What is your diagnostic and therapeutic approach to hospitalized patients with persistent hypotension (MAP <65) of uncertain etiology, but no evidence of hypoperfusion or shock physiology?

Clinical concern for MAPs <65 mmHg has become ingrained due to extensive literature on septic shock, but there is little evidence to support intervening solely at this threshold in patients without evidence of hypoperfusion. My initial approach to hypotension is therefore diagnostic: confirm it is real (often with manual measurement and an appropriately sized cuff), determine whether it is acute or chronic, evaluate for reversible causes, and assess whether the patient is adequately perfusing vital organs.

I increasingly encounter patients with low MAPs transferred from ICUs or step-down units on oral midodrine, primarily because it facilitates transfer to a lower level of care. While I appreciate the operational pressures that drive these ...

I agree with Dr. @Dr. First Last. I would add that once I confirm the hypotension is real and assess chronicity, I try to evaluate the situation in terms of perfusion rather than pressure. A MAP <65 may be seen in some patients with chronic low blood pressure, autonomic dysfunction, cirrhosis, or in those taking multiple antihypertensives. I try to use objective perfusion markers (mental status, urine output, lactate, creatinine trajectory, MAP trend, skin temperature, capillary refill) rather than reacting to a few low blood pressure readings. I also agree with your comments on midodrine: while it can help improve blood pressure, it should never replace diagnostic reasoning. I treat it as a therapy with specific indications such as orthost...