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AUTHORS' RESPONSE

Department of Geriatric Medicine University Medical Center Nijmegen The Netherlands

Address correspondence to R. W. M. M. Jansen, MD, PhD, University Medical Center Nijmegen, Department of Geriatric Medicine, 318, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands. E-mail: r.jansen{at}ger.umcn.nl

We appreciate the comments by Fisher and colleagues (1). In our study, we found that postprandial hypotension (PPH) was most prevalent in the morning and least prevalent in the evening. Indeed, other studies reported no such differences in mealtime-related postprandial changes in blood pressure. It remains open for debate whether there is indeed such a variation in postprandial blood pressure changes, and we are waiting for other studies to confirm our findings. The effect of medication, composition and size of the meal, or interobserver and intraobserver variability could not explain the variation during the day. Elevated baseline blood pressure is an important factor contributing to PPH, as we and others have found previously (2,3,4). Although not specified in our article, 5 of the 14 patients were diagnosed with hypertension and had a mean baseline systolic blood pressure of 166 ± 5 (SE) mmHg at the time of the investigation.

Fisher and colleagues suggested that it is reasonable to assume that an absolute level of postprandial systolic blood pressure of 115 mmHg or less, rather than the postprandial decline in blood pressure, is the main cause of inadequate blood supply to the brain resulting in symptoms and falls (5). In our study, the absolute level of systolic postprandial BP alone was not indicative for the presence of symptoms, but merely the extent of the decline in blood pressure after meals. All described symptoms were concurrent with declines in systolic blood pressure 20 mmHg or more, although, at all mealtimes, two patients felt sleepy at the end of the test while their systolic blood pressure had recovered to baseline levels (1). One participant with symptoms, who lost consciousness after lunch, had a decrease in systolic blood pressure with a nadir of 74 mmHg. Jansen and Lipsitz have defined postprandial hypotension as a decrease in systolic blood pressure of 20 mmHg or more within 2 hours after the start of a meal and when the absolute level of systolic blood pressure decreases to less than 90 mmHg with preprandial systolic blood pressure levels greater than 100 mmHg (2). The cerebral symptoms related to PPH probably depend on the extent to which cerebral perfusion is compromised. Due to age-related and disease-related conditions that threaten cerebral blood flow, even small postprandial changes in blood pressure may reduce cerebral oxygen delivery resulting in cerebral symptoms. A shift in the threshold for cerebral autoregulation, as occurs in hypertensive patients, might explain cerebral symptoms related to PPH at higher absolute blood pressure levels. In contrast, patients with autonomic failure can tolerate extremely low levels of postprandial systolic blood pressure without any symptoms (2). Based on our experiences and the high level of symptomatic patients, we assume that both large falls in postprandial blood pressure and low absolute levels of systolic blood pressure make frail elderly patients with comorbidity at high risk for symptomatic PPH. We underscore the need for a discussion about the criteria of (symptomatic) PPH in elderly persons, as suggested by Fisher and coworkers.

We strongly disagree with Fisher and colleagues that the majority of patients with PPH are asymptomatic. Indeed, healthy elderly persons may have declines in blood pressure after a meal without symptoms. However, many elderly patients with different diseases including hypertension, heart failure, syncope, Parkinson's disease, and depression have symptomatic PPH (6–10). We recently found, in 85 geriatric patients admitted to the hospital (mean age 80 ± 1 (SE) years), a prevalence of PPH in 67% of the patients (11). Two-thirds of these patients with PPH were symptomatic. In PPH, symptoms such as sleepiness, nausea, headache, and chest pain were present. In addition, 5 patients developed postprandial syncope. Remarkably, dizziness is absent in PPH, whereas this is the most important symptom in orthostatic hypotension. We and Fisher and colleagues emphasize the importance of early screenings for PPH in both symptomatic and asymptomatic patients because of the short-term and long-term risks of PPH such as syncope, falls, or cerebrovascular damage. Therefore, full attention should be paid to blood pressure measurements for PPH (and orthostatic hypotension) in all elderly patients. Clinicians should consider PPH in the evaluation of falls, syncope, and other cerebral ischemic symptoms.

References

1. Vloet LCM, Smits R, Jansen RWMM. The effect of meals at different mealtimes on blood pressure and symptoms in geriatric patients with postprandial hypotension. J Gerontol Biol Sci Med Sci. 2003;58:1031-1035.
2. Jansen RW, Lipsitz LA. Postprandial hypotension: epidemiology, pathophysiology, and clinical management. Ann Intern Med. 1995;122:286-295.[Abstract/Free Full Text]
3. Jansen RWMM, Penterman BJM, van Lier HJJ, Hoefnagels WHL. Blood pressure reduction after oral glucose loading and its relation to age, blood pressure and insulin. Am J Cardiol. 1987;60:1087-1091.[Medline]
4. O'Mara G, Lyons D. Postprandial hypotension. Clin Geriatr Med. 2002;18:307-321.[Medline]
5. Le Couteur DG, Fisher AA, Davis MW, McLean AJ. Postprandial systolic blood pressure responses of older people in residential care: association with risk of falling. Gerontology. 2003;49:260-264.[Medline]
6. Mehagnoul-Schipper DJ, Colier WN, Hoefnagels WH, Verheugt FW, Jansen RWMM. Effects of furosemide versus captopril on postprandial and orthostatic blood pressure and on cerebral oxygenation in patients 70 years of age with heart failure. Am J Cardiol. 2002;90:596-600.[Medline]
7. Mehagnoul-Schipper DJ, Boerman RH, Hoefnagels WHL, Jansen RWMM. Effect of levodopa on orthostatic and postprandial hypotension in elderly patients with parkinsonism. J Gerontol Biol Sci Med Sci. 2001;56A:M749-M755.
8. Kraaij van DWJ, Jansen RWMM, Bouwels LHR, Hoefnagels WHL. Furosemide withdrawal improves postprandial hypotension in elderly heart failure patients with preserved left ventricular systolic function. Arch Intern Med. 1999;159:1599-1605.[Abstract/Free Full Text]
9. Mehagnoul-Schipper DJ, Colier WN, Hoefnagels WHL, Jansen RWMM. Cerebral oxygenation changes in elderly syncope patients after eating or standing. J Am Geriatric Soc. 2003;51:(4 Suppl.): S82-S83.
10. Mehagnoul-Schipper DJ, Hulsbos HP, Hoefnagels WHL, Jansen RWMM. Influence of nortryptyline and paroxetine on postprandial and orthostatic hypotension in very old depressed patients. J Am Geriatric Soc. 2003;51:(4 Suppl.): S227.
11. Vloet LCM, Pel-Little RE, Jansen PAF, Jansen RWMM. High prevalence of postprandial and orthostatic hypotension among geriatric patients admitted to Dutch hospitals. J Gerontol Biol Sci Med Sci. In Press.

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