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Postprandial Hypotension

      Abstract

      Postprandial hypotension is both common in geriatric patients and an important but under-recognized cause of syncope. Other populations at risk include those with Parkinson disease and autonomic failure. The mechanism is not clearly understood, but appears to be secondary to a blunted sympathetic response to a meal. This review discusses the epidemiology, risk factors, and pathophysiology of postprandial hypotension in the elderly, as well as diagnosis and treatment strategies. Diagnosis can be made based on ambulatory blood pressure monitoring and patient symptoms. Lifestyle modifications such as increased water intake before eating or substituting 6 smaller meals daily for 3 larger meals may be effective treatment options. However, data from randomized, controlled trials are limited. Increased awareness of this disease may lead to improved quality of life, decreased falls and injuries, and the avoidance of unnecessary testing.

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      References

        • Seyer-Hansen K.
        Postprandial hypotension.
        Br Med J. 1977; 2: 1262
        • Lipsitz L.A.
        • Nyquist Jr, R.P.
        • Wei J.Y.
        • Rowe J.W.
        Postprandial reduction in blood pressure in the elderly.
        N Engl J Med. 1983; 309: 81-83
        • Aronow W.S.
        • Ahn C.
        Postprandial hypotension in 499 elderly persons in a long-term health care facility.
        J Am Geriatr Soc. 1994; 42: 930-932
        • Puisieux F.
        • Bulckaen H.
        • Fauchais A.L.
        • et al.
        Ambulatory blood pressure monitoring and postprandial hypotension in elderly persons with falls or syncope.
        J Gerontol A Biol Sci Med Sci. 2000; 55: M535-M540
        • Le Couteur D.G.
        • Fisher A.A.
        • Davis M.W.
        • McLean A.J.
        Postprandial systolic blood pressure responses of older people in residential care: association with risk of falling.
        Gerontology. 2003; 49: 260-264
        • Vloet L.C.
        • Pel-Little R.E.
        • Jansen P.A.
        • Jansen R.W.
        High prevalence of postprandial and orthostatic hypotension among geriatric patients admitted to Dutch hospitals.
        J Gerontol A Biol Sci Med Sci. 2005; 60: 1271-1277
        • Jansen R.W.
        • Lipsitz L.A.
        Postprandial hypotension: epidemiology, pathophysiology, and clinical management.
        Ann Intern Med. 1995; 122: 286-295
        • Lipsitz L.A.
        • Pluchino F.C.
        • Wei J.Y.
        • et al.
        Cardiovascular and norepinephrine responses after meal consumption in elderly (older than 75 years) persons with postprandial hypotension and syncope.
        Am J Cardiol. 1986; 58: 810-815
        • Aronow W.S.
        • Ahn C.
        Association of postprandial hypotension with incidence of falls, syncope, coronary events, stroke, and total mortality at 29-month follow-up in 499 older nursing home residents.
        J Am Geriatr Soc. 1997; 45: 1051-1053
        • Kohara K.
        • Jiang Y.
        • Igase M.
        • et al.
        Postprandial hypotension is associated with asymptomatic cerebrovascular damage in essential hypertensive patients.
        Hypertension. 1999; 33: 565-568
        • Kamata T.
        • Yokota T.
        • Furukawa T.
        • Tsukagoshi H.
        Cerebral ischemic attack caused by postprandial hypotension.
        Stroke. 1994; 25: 511-513
        • Cheshire Jr, W.P.
        • Meschia J.F.
        Postprandial limb-shaking: an unusual presentation of transient cerebral ischemia.
        Clin Auton Res. 2006; 16: 243-246
        • Fisher A.A.
        • Davis M.W.
        • Srikusalanukul W.
        • Budge M.M.
        Postprandial hypotension predicts all-cause mortality in older, low-level care residents.
        J Am Geriatr Soc. 2005; 53: 1313-1320
        • Mitro P.
        • Feterik K.
        • Cverckova A.
        • Trejbal D.
        Occurrence and relevance of postprandial hypotension in patients with essential hypertension.
        Wien Klin Wochenschr. 1999; 111: 320-325
        • Jansen R.W.
        • Kelly-Gagnon M.M.
        • Lipsitz L.A.
        Intraindividual reproducibility of postprandial and orthostatic blood pressure changes in older nursing-home patients: relationship with chronic use of cardiovascular medications.
        J Am Geriatr Soc. 1996; 44: 383-389
        • Gentilcore D.
        • Hausken T.
        • Meyer J.H.
        • et al.
        Effects of intraduodenal glucose, fat, and protein on blood pressure, heart rate, and splanchnic blood flow in healthy older subjects.
        Am J Clin Nutr. 2008; 87: 156-161
        • Vloet L.C.
        • Mehagnoul-Schipper D.J.
        • Hoefnagels W.H.
        • Jansen R.W.
        The influence of low-, normal-, and high-carbohydrate meals on blood pressure in elderly patients with postprandial hypotension.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M744-M748
        • Kearney M.T.
        • Cowley A.J.
        • Stubbs T.A.
        • et al.
        Depressor action of insulin on skeletal muscle vasculature: a novel mechanism for postprandial hypotension in the elderly.
        J Am Coll Cardiol. 1998; 31: 209-216
        • Kuipers H.M.
        • Jansen R.W.
        • Peeters T.L.
        • Hoefnagels W.H.
        The influence of food temperature on postprandial blood pressure reduction and its relation to substance-P in healthy elderly subjects.
        J Am Geriatr Soc. 1991; 39: 181-184
        • Vloet L.C.
        • Smits R.
        • Jansen R.W.
        The effect of meals at different mealtimes on blood pressure and symptoms in geriatric patients with postprandial hypotension.
        J Gerontol A Biol Sci Med Sci. 2003; 58: 1031-1035
        • Kohara K.
        • Uemura K.
        • Takata Y.
        • et al.
        Postprandial hypotension: evaluation by ambulatory blood pressure monitoring.
        Am J Hypertens. 1998; 11: 1358-1363
        • Puisieux F.
        • Court D.
        • Baheu E.
        • et al.
        Intraindividual reproducibility of postprandial hypotension.
        Gerontology. 2002; 48: 315-320
        • Mader S.L.
        Effects of meals and time of day on postural blood pressure responses in young and elderly subjects.
        Arch Intern Med. 1989; 149: 2757-2760
        • Maurer M.S.
        • Karmally W.
        • Rivadeneira H.
        • et al.
        Upright posture and postprandial hypotension in elderly persons.
        Ann Intern Med. 2000; 133: 533-536
        • Lipsitz L.A.
        • Fullerton K.J.
        Postprandial blood pressure reduction in healthy elderly.
        J Am Geriatr Soc. 1986; 34: 267-270
        • Jones K.L.
        • Tonkin A.
        • Horowitz M.
        • et al.
        Rate of gastric emptying is a determinant of postprandial hypotension in non-insulin-dependent diabetes mellitus.
        Clin Sci (Lond). 1998; 94: 65-70
        • Tanakaya M.
        • Takahashi N.
        • Takeuchi K.
        • et al.
        Postprandial hypotension due to a lack of sympathetic compensation in patients with diabetes mellitus.
        Acta Med Okayama. 2007; 61: 191-197
        • Loew F.
        • Gauthey L.
        • Koerffy A.
        • et al.
        Postprandial hypotension and orthostatic blood pressure responses in elderly Parkinson's disease patients.
        J Hypertens. 1995; 13: 1291-1297
        • Mehagnoul-Schipper D.J.
        • Boerman R.H.
        • Hoefnagels W.H.
        • Jansen R.W.
        Effect of levodopa on orthostatic and postprandial hypotension in elderly Parkinsonian patients.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M749-M755
        • Sherman R.A.
        • Torres F.
        • Cody R.P.
        Postprandial blood pressure changes during hemodialysis.
        Am J Kidney Dis. 1988; 12: 37-39
        • Zoccali C.
        • Mallamaci F.
        • Ciccarelli M.
        • Maggiore Q.
        Postprandial alterations in arterial pressure control during hemodialysis in uremic patients.
        Clin Nephrol. 1989; 31: 323-326
        • Pugliese P.
        • Annesi G.
        • Cutuli N.
        • et al.
        The fragile X premutation presenting as postprandial hypotension.
        Neurology. 2004; 63: 2188-2189
        • Bellomo G.
        • Santambrogio L.
        • Berioli S.
        • et al.
        Non-invasive cardiovascular monitoring in Shy-Drager syndrome.
        Acta Neurol (Napoli). 1989; 11: 279-284
        • Kooner J.S.
        • Raimbach S.
        • Watson L.
        • et al.
        Relationship between splanchnic vasodilation and postprandial hypotension in patients with primary autonomic failure.
        J Hypertens Suppl. 1989; 7: S40-S41
        • Jansen R.W.
        • Connelly C.M.
        • Kelley-Gagnon M.M.
        • et al.
        Postprandial hypotension in elderly patients with unexplained syncope.
        Arch Intern Med. 1995; 155: 945-952
        • Lipsitz L.A.
        • Ryan S.M.
        • Parker J.A.
        • et al.
        Hemodynamic and autonomic nervous system responses to mixed meal ingestion in healthy young and old subjects and dysautonomic patients with postprandial hypotension.
        Circulation. 1993; 87: 391-400
        • Imai C.
        • Muratani H.
        • Kimura Y.
        • et al.
        Effects of meal ingestion and active standing on blood pressure in patients>or=60 years of age.
        Am J Cardiol. 1998; 81: 1310-1314
        • Fagius J.
        • Ellerfelt K.
        • Lithell H.
        • Berne C.
        Increase in muscle nerve sympathetic activity after glucose intake is blunted in the elderly.
        Clin Auton Res. 1996; 6: 195-203
        • van Orshoven N.P.
        • van Schelven L.J.
        • Akkermans L.M.
        • et al.
        The effect of intraduodenal glucose on muscle sympathetic nerve activity in healthy young and older subjects.
        Clin Auton Res. 2008; 18: 28-35
        • Ryan S.M.
        • Goldberger A.L.
        • Ruthazer R.
        • et al.
        Spectral analysis of heart rate dynamics in elderly persons with postprandial hypotension.
        Am J Cardiol. 1992; 69: 201-205
        • Masuda Y.
        • Kawamura A.
        Role of the autonomic nervous system in postprandial hypotension in elderly persons.
        J Cardiovasc Pharmacol. 2003; 42: S23-S26
        • Mitro P.
        • Feterik K.
        • Lenartova M.
        • et al.
        Humoral mechanisms in the pathogenesis of postprandial hypotension in patients with essential hypertension.
        Wien Klin Wochenschr. 2001; 113: 424-432
        • Micieli G.
        • Martignoni E.
        • Cavallini A.
        • et al.
        Postprandial and orthostatic hypotension in Parkinson's disease.
        Neurology. 1987; 37: 386-393
        • Thomaides T.
        • Bleasdale-Barr K.
        • Chaudhuri K.R.
        • et al.
        Cardiovascular and hormonal responses to liquid food challenge in idiopathic Parkinson's disease, multiple system atrophy, and pure autonomic failure.
        Neurology. 1993; 43: 900-904
        • Vaitkevicius P.V.
        • Esserwein D.M.
        • Maynard A.K.
        • et al.
        Frequency and importance of postprandial blood pressure reduction in elderly nursing-home patients.
        Ann Intern Med. 1991; 115: 865-870
        • Grodzicki T.
        • Rajzer M.
        • Fagard R.
        • et al.
        Ambulatory blood pressure monitoring and postprandial hypotension in elderly patients with isolated systolic hypertension.
        J Hum Hypertens. 1998; 12: 161-165
        • Deguchi K.
        • Ikeda K.
        • Sasaki I.
        • et al.
        Effects of daily water drinking on orthostatic and postprandial hypotension in patients with multiple system atrophy.
        J Neurol. 2007; 254: 735-740
        • Shannon J.R.
        • Diedrich A.
        • Biaggioni I.
        • et al.
        Water drinking as a treatment for orthostatic syndromes.
        Am J Med. 2002; 112: 355-360
        • Jones K.L.
        • O'Donovan D.
        • Russo A.
        • et al.
        Effects of drink volume and glucose load on gastric emptying and postprandial blood pressure in healthy older subjects.
        Am J Physiol Gastrointest Liver Physiol. 2005; 289: G240-G248
        • Gentilcore D.
        • Meyer J.H.
        • Rayner C.K.
        • et al.
        Gastric distension attenuates the hypotensive effect of intraduodenal glucose in healthy older subjects.
        Am J Physiol Regul Integr Comp Physiol. 2008; 295: R472-R477
        • Puvi-Rajasingham S.
        • Mathias C.J.
        Effect of meal size on post-prandial blood pressure and on postural hypotension in primary autonomic failure.
        Clin Auton Res. 1996; 6: 111-114
        • Oberman A.S.
        • Harada R.K.
        • Gagnon M.M.
        • et al.
        Effects of postprandial walking exercise on meal-related hypotension in frail elderly patients.
        Am J Cardiol. 1999; 84 (A11): 1130-1132
        • van Kraaij D.J.
        • Jansen R.W.
        • Bouwels L.H.
        • Hoefnagels W.H.
        Furosemide withdrawal improves postprandial hypotension in elderly patients with heart failure and preserved left ventricular systolic function.
        Arch Intern Med. 1999; 159: 1599-1605
        • Mehagnoul-Schipper D.J.
        • Colier W.N.
        • Hoefnagels W.H.
        • et al.
        Effects of furosemide versus captopril on postprandial and orthostatic blood pressure and on cerebral oxygenation in patients>or=70 years of age with heart failure.
        Am J Cardiol. 2002; 90: 596-600
        • Onrot J.
        • Goldberg M.R.
        • Biaggioni I.
        • et al.
        Hemodynamic and humoral effects of caffeine in autonomic failure.
        N Engl J Med. 1985; 313: 549-554
        • Rakic V.
        • Beilin L.J.
        • Burke V.
        Effect of coffee and tea drinking on postprandial hypotension in older men and women.
        Clin Exp Pharmacol Physiol. 1996; 23: 559-563
        • Heseltine D.
        • el-Jabri M.
        • Ahmed F.
        • Knox J.
        The effect of caffeine on postprandial blood pressure in the frail elderly.
        Postgrad Med J. 1991; 67: 543-547
        • Heseltine D.
        • Dakkak M.
        • Woodhouse K.
        • et al.
        The effect of caffeine on postprandial hypotension in the elderly.
        J Am Geriatr Soc. 1991; 39: 160-164
        • Lipsitz L.A.
        • Jansen R.W.
        • Connelly C.M.
        • et al.
        Haemodynamic and neurohumoral effects of caffeine in elderly patients with symptomatic postprandial hypotension: a double-blind, randomized, placebo-controlled study.
        Clin Sci (Lond). 1994; 87: 259-267
        • Shibao C.
        • Gamboa A.
        • Diedrich A.
        • et al.
        Acarbose, an alpha-glucosidase inhibitor, attenuates postprandial hypotension in autonomic failure.
        Hypertension. 2007; 50: 54-61
        • Maruta T.
        • Komai K.
        • Takamori M.
        • Yamada M.
        Voglibose inhibits postprandial hypotension in neurologic disorders and elderly people.
        Neurology. 2006; 66: 1432-1434
        • Gentilcore D.
        • Bryant B.
        • Wishart J.M.
        • et al.
        Acarbose attenuates the hypotensive response to sucrose and slows gastric emptying in the elderly.
        Am J Med. 2005; 118: 1289.e5-1289.e11
        • O'Donovan D.
        • Feinle-Bisset C.
        • Chong C.
        • et al.
        Intraduodenal guar attenuates the fall in blood pressure induced by glucose in healthy older adults.
        J Gerontol A Biol Sci Med Sci. 2005; 60: 940-946
        • Jansen R.W.
        • Peeters T.L.
        • Lenders J.W.
        • et al.
        Somatostatin analog octreotide (SMS 201-995) prevents the decrease in blood pressure after oral glucose loading in the elderly.
        J Clin Endocrinol Metab. 1989; 68: 752-756
        • Hoeldtke R.D.
        • Davis K.M.
        • Joseph J.
        • et al.
        Hemodynamic effects of octreotide in patients with autonomic neuropathy.
        Circulation. 1991; 84: 168-176
        • Hoeldtke R.D.
        • Dworkin G.E.
        • Gaspar S.R.
        • et al.
        Effect of the somatostatin analogue SMS-201-995 on the adrenergic response to glucose ingestion in patients with postprandial hypotension.
        Am J Med. 1989; 86: 673-677
        • Alam M.
        • Smith G.
        • Bleasdale-Barr K.
        • et al.
        Effects of the peptide release inhibitor, octreotide, on daytime hypotension and on nocturnal hypertension in primary autonomic failure.
        J Hypertens. 1995; 13: 1664-1669
        • Hirayama M.
        • Watanabe H.
        • Koike Y.
        • et al.
        Treatment of postprandial hypotension with selective alpha 1 and beta 1 adrenergic agonists.
        J Auton Nerv Syst. 1993; 45: 149-154
        • Hakusui S.
        • Sugiyama Y.
        • Iwase S.
        • et al.
        Postprandial hypotension: microneurographic analysis and treatment with vasopressin.
        Neurology. 1991; 41: 712-715