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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 55:M535-M540 (2000)
© 2000 The Gerontological Society of America

Ambulatory Blood Pressure Monitoring and Postprandial Hypotension in Elderly Persons With Falls or Syncopes

François Puisieuxa, Hélène Bulckaena, Anne Laure Fauchaisa, Sylvie Drumeza, Françoise Salomez-Graniera and Philippe Dewaillya

a Department of Internal Medicine and Geriatrics, Hôpital Gériatrique les Bateliers, Centre Hospitalier Régional, and University of Lille, France

François Puisieux, Service de M\|[eacute]\|decine Interne et de G\|[eacute]\|riatrie, H\|[ocirc ]\|pital G\|[eacute]\|riatrique les Bateliers, CHRU Lille, 59037 Lille Cedex, France E-mail: fpuisieux{at}nordnet.fr.

William B. Ershler, MD


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. Postprandial hypotension (PPH) is increasingly recognized as a common cause of falls and syncope in elderly persons. Noninvasive ambulatory blood pressure monitoring (ABPM) has been recommended for detecting PPH. This study investigates postprandial blood pressure (BP) changes by means of ABPM in elderly patients experiencing falls or syncopes.

Methods. Twenty-four-hour ABPM was performed in 156 inpatients (111 women, mean age 80.4 ± 8.1 years). Among them, 45 had been admitted for falls and 75 for syncope; 36 with no history of falls or syncope served as controls. Postprandial change in systolic blood pressure ({Delta}SBP) was calculated by subtracting the mean SBP within the 2 hours following the meal from the mean SBP within the 2 hours preceding the meal. PPH was defined by a {Delta}SBP >= 20 mm Hg.

Results. For the entire group, mean SBP decreased after the three meals. On average, the decline in SBP was greater after breakfast than after lunch or dinner, and the number of patients experiencing PPH was greater after breakfast. Average maximal {Delta}SBP was significantly larger in the syncope group than in the other groups ( p < .05). Moreover, the number of patients experiencing PPH was significantly higher in the syncope/fall group than in the control group (23% vs 9%; p = .03). Compared with patients without PPH, patients with PPH were more likely to have a history of diabetes mellitus (p < .01) or to use more than three different drugs daily ( p = .04), and they showed greater daytime SBP variability (p < .0001). Furthermore, there was a strong positive correlation between preprandial SBP and {Delta}SBP after breakfast.

Conclusions. About one out of four elderly patients with falls or syncope experiences PPH, usually after breakfast. Postprandial decline in BP contributes to BP variability. {Delta}SBP and preprandial SBP are positively correlated.

FALLS and syncope are common symptoms in elderly persons and may be caused by a large variety of disorders (1)(2)(3). Over the past decade, postprandial hypotension (PPH) (4)(5)(6)(7)(8) has been recognized as a common cause of syncope and falls in elderly persons. Noninvasive ambulatory blood pressure monitoring (ABPM) is considered a valuable and useful test for the management of patients with hypertension and particularly to eliminate "white-coat hypertension," to confirm the diagnosis of borderline hypertension, to assess the circadian rhythm of blood pressure (BP), or to evaluate treatment-resistant hypertension (9)(10)(11)(12)(13)(14)(15). Furthermore, ambulatory BP measurements have a better correlation with the presence of target organ complications of hypertensive disease than do office BP values, and ABPM is superior to office BP in predicting cardiovascular morbidity (9)(12). Because ABPM can produce considerable information about BP variations, it has been suggested that ABPM may be a useful test to detect abrupt changes in BP in elderly persons, especially after a meal or with changes in posture (7)(10)(14)(16). However, data are scanty in support of this assertion. Only a few studies using ABPM have been designed to assess postprandial changes in BP (17)(18)(19)(20)(21)(22). Only three of the studies reported on elderly patients (17)(20)(21), and to the best of our knowledge, none have addressed the particularities of BP profile in elderly patients with falls or syncopes. Our study investigates postprandial BP changes by means of ABPM in elderly patients with falls or syncopes and, for comparison, in control patients without such a history.


   Methods
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 Abstract
 Methods
Results
 Discussion
 References
 
Setting
The site for our study was a geriatric short-stay department with 30 beds. During the period of the study, the total number of admissions was 748. The mean length of stay was 11.2 days.

Patients
Between February 1996 and January 1997, all patients who were admitted to our department of acute geriatric medicine for investigation of falls or syncope were invited to participate in the study provided they fulfilled the following criteria: (a) were >=60 years old; (b) provided informed consent to participate in the study; and (c) had no history of myocardial infarction or stroke within the preceding 6 months. Thirty-four inpatients without a history of falls or loss of consciousness and who agreed to participate in the study served as controls.

Baseline Evaluation of Patients
For all patients, we obtained a complete history and physical examination, including details of medication use. A postural test was performed on each patient; orthostatic hypotension (OH) was defined by a systolic blood pressure (SBP) decline >=20 mm Hg within 3 minutes after standing.

ABPM
During their hospitalization, all patients and controls underwent 24-hour ABPM using the Spacelabs 90207 monitor (SpaceLabs, Inc., Workingham, Beckshire, England), which has been validated according to British Hypertension Society criteria for use in elderly persons (23). The monitoring began at 10:00 AM. The monitor was programmed to take readings every 15 minutes during the day (7:00 AM to 10:00 PM) and every 30 minutes at night (10:00 PM to 7:00 AM). An appropriately sized cuff was applied to the left arm. For each patient, the average BP and the BP variability (SD of mean value) were calculated for 24 hours and for the periods corresponding to day and night. The circadian BP was considered as reversed when mean SBP during the day period was lower than mean SBP during the night period. In the hospital, meals are taken at set times; between 8:00 and 8:30 AM for breakfast; between 12:00 and 12:30 PM for lunch; between 6:00 and 6:30 PM for dinner. All patients took meals sitting, in their rooms. According to the definition of Grodziki and coworkers (21), postprandial SBP decline ({Delta}SBP) was defined by the following equation: {Delta}SBP = preprandial SBP - postprandial SBP where preprandial SBP = average SBP during the 2 hours preceding the meal, and postprandial SBP = average SBP during the 2 hours following the meal. PPH was defined by a {Delta}SBP >= 20 mm Hg. Only recordings with complete measurements of the BP variations at the time of the three meals were included (at least two readings per hour during the 2 hours before and the 2 hours after each meal). Each patient was asked about his or her waking time, time of falling asleep, and quality of his or her sleep.

Statistical Analysis
The results were expressed in mean values ± SD. The groups were compared by chi-square test for categorical variables and by analysis of variance or Student's t test for continuous variables for series, paired or not. The relation between postprandial change in BP and preprandial SBP for each patient was calculated using standard linear regression techniques. A value of p < .05 was considered statistically significant.


   Results
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 Abstract
 Methods
 Results
Discussion
 References
 
Study Group
During the study period, 152 consecutive patients aged 60 years and older (47 men and 105 women) were admitted for falls or syncopes. Among them, only two patients declined to participate; 30 patients were secondarily excluded from the study because of an unsatisfactory 24-hour BP recording. Most of these patients had dementia or a confusional state. The remaining group included 120 patients (87 women and 33 men), mean age 81.1 ± 8 years (range from 62 to 95 years), admitted for falls without syncope (n = 45) or with syncope (n = 75). Thirty-six patients without a history of falls or syncope were recruited to serve as controls. They were similar to patients in age, gender, activities of daily living (ADL), and other primary clinical characteristics (Table 1 ).


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  		Table 1. Clinical Features and Medication Use in Patients and Controls

 
ABPM
The most common side effect related by the patients was sleep disturbance, which occurred in one of five patients. Mean (±SD) systolic and diastolic BP, heart rate, and variabilities of systolic and diastolic BP during the diurnal and the nocturnal periods were not different between the three groups (Table 2 ).


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  		Table 2. Mean Systolic (SBP) and Diastolic (DBP) Blood Pressure and Heart Rate (HR) During the Diurnal Activity and the Nocturnal Rest Periods and Standard Deviation (SD) of SBP, DBP, and HR During the Diurnal and Nocturnal Periods in Patients With Falls or Syncope and Controls

 
For the entire group (156 patients), SBP decreased after the three meals (Fig. 1). When the postprandial change in BP ({Delta}SBP) was assessed by comparing the mean SBP in the 2 hours before and after the meals, the decline in SBP, on average, was greater after breakfast (5.3 ± 13.4) than after lunch (3.4 ± 9.1) or after dinner (2.6 ± 10.5), but the difference did not reach statistical significance (p = .1).



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  		Figure 1. Mean systolic blood pressure before and after lunch, dinner, and breakfast in controls and in patients with falls or syncope.

 
On average, {Delta}SBP was slightly greater among the patients with syncopes or falls than among the controls (respectively, 4.5 ± 5.7, and 3.8 ± 7.5 vs 1.8 ± 6.6 in the control group; p = .015) (Fig. 2). All patients experienced at least one (after one of the three meals) decline in SBP. For each patient, we obtained three measurements of postprandial SBP change (one for breakfast, one for lunch, one for dinner); thus we could consider the maximal postprandial decline in SBP (max {Delta}SBP). On average, max {Delta}SBP was significantly different between the three groups (13.4 ± 9.0 in the syncope group, 12.4 ± 11.2 in the fall group, and 8.6 ± 8.9 in the control group; p < .05). As illustrated by the histogram of the max {Delta}SBP for all patients (Fig. 3), 31 (20%) patients experienced PPH (defined by a {Delta}SBP >= 20 mm Hg). PPH was observed after breakfast in 14 patients, after lunch in eight patients, and after dinner in nine patients. The number of patients experiencing PPH was significantly greater in the syncope/fall group than in the control group (20 patients [27%] in the syncope group and 8 patients [18%] in the fall group vs 3 patients [8.5%] in the control group; p < .05).



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  		Figure 2. Average systolic blood pressure decline ({Delta}SBP) in controls and in patients with falls or syncope. *p < .05 postprandial SBP versus preprandial SBP.

 


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  		Figure 3. Histogram of the maximal postprandial decline in controls and in patients with falls or syncope.

 
Comparison of Patients With and Without PPH
Demographic and clinical features of patients with and without PPH are shown in Table 3 . There was no significant difference in age, gender, body mass index (BMI), ADL, history of hypertension, heart failure, stroke, coronary disease, and prevalence of OH. Patients with PPH were more likely to have a history of diabetes mellitus (p < .01) and to use more than three different drugs daily (p = .04). ABPM data in patients with and without PPH are summarized in Table 4 . We found a tendency toward higher values of BP in patients with PPH (the difference was significant only for nocturnal SBP). The diurnal SBP variability and the coefficient of variability (variability/SBP) were significantly higher in the PPH group (p < .0001). However, the prevalence of reversed circadian rhythm of BP was not significantly different between the two groups.


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  		Table 3. Clinical Features and Medication Use in Patients With and Without Postprandial Hypotension (PPH)

 

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  		Table 4. Mean Systolic (SBP) and Diastolic (DBP) Blood Pressure and Heart Rate (HR) During the Diurnal Activity and the Nocturnal Rest Periods and Standard Deviation (SD) of SBP, DBP, and HR During the Diurnal and Nocturnal Periods in Patients With and Without Postprandial Hypotension (PPH)

 
Relationship Between Preprandial SBP and {Delta}SBP
Fig. 4 illustrates the strong positive correlation observed between preprandial SBP and {Delta}SBP after breakfast that fit a linear regression equation (r = .51, p < .0001). A significant positive relationship was also observed between preprandial SBP and {Delta}SBP after lunch (r = .38, p < .001).



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  		Figure 4. Relationship between preprandial systolic blood pressure (pre-SBP) and postprandial SBP decline ({Delta}SBP) after breakfast in the 156 patients.

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
The main findings in the present study were as follows: (1) the prevalence of PPH (defined by a {Delta}SBP >= 20 mm Hg) was high among elderly subjects hospitalized for falls or syncope (23%); (2) on average, the decline in SBP was greater after breakfast than after lunch or dinner, and the number of patients experiencing PPH was greater after breakfast; (3) compared with patients without PPH, those with PPH were more likely to have a history of diabetes mellitus or to use more than three different drugs daily; (4) PPH increased diurnal BP variability independently of nocturnal change in BP; and (5) preprandial SBP and {Delta}SBP were positively correlated, especially at breakfast time.

Although it has been suggested that ABPM may be a useful test to detect PPH in elderly persons, only a few studies have addressed this problem (17)(21)(22). There is no standardized definition for PPH (7). However, by analogy with OH, PPH is usually defined as a decrease in SBP of 20 mm Hg or more after meal ingestion (7). Because BP usually reaches a nadir within 15 to 75 minutes after the start of a meal (7), we took into account the mean BP during the 2 hours following the meal and, for comparison, the mean BP during the 2 hours preceding the meal. The definition used for PPH in the present study is identical to that used in a recent study by Grodziki and coworkers (21) and close to that used in a recent study by Kohara and coworkers (22), which allows for comparisons. Grodziki's study included 530 elderly patients (aged 60 to 100 years) participating in the Systolic Hypertension in Europe study, 70% of whom experienced some decline in BP after the main meal and one quarter of whom experienced a decrease of more than 16 mm Hg (21). Although our study population is rather different, we observed relatively similar results because approximately 20% of the subjects in our study experienced PPH ({Delta}SBP >= 20 mm Hg). In Kohara's study, which included 121 hospitalized, essential hypertensive, patients (65 patients were >=60 years) (22), the postprandial BP decline showed age-dependent augmentation, and the mean postprandial BP decline was 7 ± 12.8 mm Hg among patients aged 70 years and older.

We observed that the maximal postprandial decline was significantly greater in the syncope group than in the fall group or in the control group (p < .05). We also found a higher prevalence of PPH in the fall/syncope group than in the control group (23% vs 8%; p < .05). This result is in agreement with other recent studies (5)(6)(7)(8) and constitutes a supplementary argument in favor of the hypothesis according to which PPH predisposes the elderly subject to falls and syncopes. In our study, PPH was significantly correlated with a history of diabetes mellitus. Previous studies have suggested that autonomic dysfunction caused by diabetes is a risk factor for PPH (7). We did not find any relationship between age, gender, BMI, ADL, and PPH. However, patients with PPH were more likely to use more than three different drugs daily. We failed to incriminate a therapeutic class in particular. In the literature, data concerning the link between drug use and PPH are scarce. In Aronow's study (6), which included 499 nursing home residents, the mean maximal reduction in postprandial SBP was significantly greater in patients treated with angiotension converting enzyme inhibitors, calcium blockers, diuretics, nitrates, and psychotropic drugs than in others. In Vaitkevicius's study (5), PPH occurred more frequently in patients using vasodilatators. Most of these drugs may promote PPH by reducing cardiac preload.

We observed a slightly higher prevalence of OH in the PPH group than in the non-PPH group, but the difference was not significant. Our results are in agreement with those of Jansen and colleagues (24) and indicate that OH and PPH do not occur necessarily in the same patients, suggesting that the mechanisms and causes of PPH differ at least partly from those of OH.

In our study, the average {Delta}SBP and the incidence of PPH were higher after breakfast than after lunch or after dinner. A similar observation was made by Kohara and coworkers (22) in their series of hypertensive patients. It has been demonstrated that the magnitude of the decrease in postprandial BP depends partly on the type of food ingested, especially on the quantity of glucose ingested and on the temperature of the meal (7). Because, in our study, the meals were not standardized, we can suppose that the breakfast composition was the most likely to induce PPH. We also can suspect a drug effect because a number of drugs are given at breakfast time. Our results suggest another possible explanation. Indeed, we observed a higher prevalence of PPH at breakfast time when preprandial SBP was highest and a positive correlation between preprandial SBP and {Delta}SBP. These findings suggest that the more elevated the preprandial SBP, the larger the postprandial BP decline and the higher the risk for PPH. Such a relationship between preprandial SBP and {Delta}SBP has been previously observed by Vaitkevicius and coworkers (5) in a series of 113 nursing-home residents and by Kohara and coworkers (22) using ABPM in a series of 121 hypertensive patients. Furthermore, Kohara and colleagues (22) observed a significant relationship between morning surge of BP and PPH at breakfast time.

The pathogenesis of PPH is not fully understood (7)(25)(26). Meal ingestion has been demonstrated to induce splanchnic vasodilatation and decrease in systemic vascular resistance, which may provoke a decrease in venous return and cause PPH (7). However, the amount of splanchnic blood pooling is not correlated with the magnitude of {Delta}SBP after meal ingestion (25), suggesting that excessive blood pooling during digestion is not the principal mechanism for PPH (7). There is evidence that PPH occurs when cardiovascular compensation for the meal-induced splanchnic vasodilatation is not adequate, because of inability to increase cardiac output or peripheral vascular resistance due to impaired baroreflex and/or peripheral sympathic nervous functions (7)(25). The exact role of insulin and other vasoactive peptides is still controversial (7)(26). Because hypertension impairs baroreflex sensitivity and diastolic ventricular filling that renders the heart more dependent on ventricular preload, it increases the risk for PPH (7)(26). We also observed a correlation between PPH and BP variability, which is considered as a cardiovascular risk factor (11). As baroreflex dysfunction has been shown to contribute to both morning surge in BP and BP variability (27)(28), our findings that {Delta}SBP, preprandial SPB, and BP variability are correlated support the involvement of baroreflex dysfunction in the pathogenesis of PPH.

In conclusion, the present study demonstrates that PPH is detected by ABPM in one out of four elderly patients with falls and syncope, usually after breakfast. It also suggests that PPH contributes to diurnal BP variability and that postprandial BP decline is positively related to preprandial SBP.

Received June 16, 1999

Accepted December 13, 1999


   References
Top
 Abstract
 Methods
 Results
 Discussion
 References
 

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