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Postprandial Hypotension in Elderly Patients With Unexplained Syncope

Postprandial Hypotension in Elderly Patients With Unexplained Syncope Abstract Background: Syncope in older patients may be caused by a variety of disorders, including hypotension, but frequently remains unexplained. Postprandial hypotension is a common disorder of blood pressure regulation in the elderly. Objective: To determine the pathogenic mechanisms and potential role of postprandial hypotension in elderly patients with otherwise unexplained syncope. Methods: We studied 16 elderly patients with unexplained syncope and nine elderly controls. Blood pressure, heart rate, forearm vascular resistance, plasma norepinephrine level, and cardiac and splanchnic blood volumes were measured before and after a 1680-kJ meal. Results: Eight elderly patients with syncope had postprandial hypotension, with a decline in supine mean arterial blood pressure of 17±2 mm Hg after a meal (P<.001). The blood pressure remained unchanged after the meal in the other patients with syncope and the controls. In patients with postprandial hypotension, systemic vascular resistance fell after the meal, while it remained unchanged in the other groups. Heart rate and plasma norepinephrine level increased to a similar extent in all three groups. Forearm vascular resistance increased only in the control subjects. Splanchnic blood volume increased by 26% (P<.01) in patients with syncope who had postprandial hypotension and by 22% (P<.01) in control subjects. Splanchnic blood volume remained unchanged in the patients with syncope without postprandial hypotension. Conclusions: Postprandial hypotension may be an important causative factor in elderly patients with unexplained syncope. The evaluation of syncope in elderly patients should therefore include blood pressure measurements surrounding a meal. Elderly patients with syncope who have postprandial hypotension fail to maintain systemic vascular resistance, probably because of splanchnic blood pooling without a compensatory increase in peripheral vascular resistance.(Arch Intern Med. 1995;155:945-952) References 1. Lipsitz LA. Syncope in the elderly. Ann Intern Med . 1983;99:92-105.Crossref 2. Kapoor WN, Karpf M, Maher Y, Miller MA, Levey GS. Syncope of unknown origin: the need for a more cost-effective approach to its diagnostic evaluation. JAMA . 1982;247:2687-2691.Crossref 3. Kapoor W, Snustad D, Peterson J, Wieand H, Cha R, Karpf M. Syncope in the elderly. Am J Med . 1986;80:419-428.Crossref 4. Lipsitz LA, Pluchino FC, Wei JY, Rowe JW. Syncope in institutionalized elderly: the impact of multiple pathological conditions and situational stress. J Chronic Dis . 1986;39:619-630.Crossref 5. Lipsitz LA, Nyqvist RP, Wei JY, Rowe JW. Postprandial reduction in blood pressure in the elderly. N Engl J Med . 1983;309:81-83.Crossref 6. Westenend M, Lenders JWM, Thien T. The course of blood pressure after a meal: a difference between young and elderly subjects. J Hypertens . 1985;3 ( (suppl 3) ):S417-S419. 7. Lipsitz LA, Fullerton KJ. Postprandial blood pressure reduction in healthy elderly. JAm Geriatr Soc . 1986;34:267-270. 8. Peitzman SJ, Berger SR. Postprandial blood pressure decrease in well elderly persons. Arch Intern Med . 1989;149:286-288.Crossref 9. Jansen RWMM, Lenders JWM, Thien T, Hoefnagels WHL. Antihypertensive treatment and postprandial blood pressure reduction in the elderly. Gerontology . 1987;95:363-368.Crossref 10. 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.Crossref 11. Bellomo G, Santucci S, Aisa G, Parnetti L. Meal-induced arterial blood pressure variations in the elderly. Gerontology . 1988;34:311-314.Crossref 12. Vaitkevicius PV, Esserwein DM, Maynard AK, O'Connor FC, Fleg JL. Frequency and importance of postprandial blood pressure reduction in elderly nursing-home patients. Ann Intern Med . 1991;115:865-870.Crossref 13. Robertson D, Wade D, Robertson RM. Postprandial alterations in cardiovascular hemodynamics in autonomic dysfunctional states. Am J Cardiol . 1981; 48:1048-1052.Crossref 14. Hoeldtke RD, O'Dorisio TM, Boden G. Treatment of autonomic neuropathy with a somatostain analogue SMS 201-995. Lancet . 1986;2:602-605.Crossref 15. Mathias CJ, Da Costa DF, McIntosh CM, et al. Differential blood pressure and hormonal effects after glucose and xylose ingestion in chronic autonomic failure. Clin Sci . 1989;77:85-92. 16. Micieli G, Martignoni E, Cavallini A, Sandrini G, Nappi G. Postprandial and orthostatic hypotension in Parkinson's disease. Neurology . 1987;37:386-393.Crossref 17. Sherman RA, Torres F, Cody RP. Postprandial blood pressure changes during hemodialysis. Am J Kidney Dis . 1988;12:37-39.Crossref 18. Lipsitz LA, Pluchino FC, Wei JY, Minaker ML, Rowe JW. 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.Crossref 19. Jansen RWMM, Hoefnagels WHL. The influence of oral glucose loading on baroreflex function in the elderly. J Am Geriatr Soc . 1989;37:1017-1022. 20. Raimbach SJ, Cortelli P, Kooner JS, Bannister R, Peart WS, Mathias CJ. Prevention of glucose-induced hypotension by the somatostain analogue octreotide (SMS 201-995) in chronic autonomic failure: haemodynamic and hormonal changes. Clin Sci . 1989;77:623-628. 21. Hoeldtke RD, Davis KM, Joseph J, Gonzales R, Panidis IP, Friedman AC. Hemodynamic effects of octreotide in patients with autonomic neuropathy. Circulation . 1991;84:168-176.Crossref 22. Hoeldtke RD, O'Dorisio TM, Boden G. Prevention of postprandial hypotension with somatostatin. Ann Intern Med . 1985;103:889-890.Crossref 23. Jansen RWMM, Peeters TL, Lenders JWM, van Lier HJJ, van't Laar A, Hoefnagels WHL. Somatostatin analogue octreotide (SMS 201-995) prevents the decrease of blood pressure after oral glucose loading in the elderly. J Clin Endocrinol Metab . 1989;68:752-756.Crossref 24. Kuipers HMM, Jansen RWMM, Peeters TL, Hoefnagels WHL. 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. 25. Jansen RWMM, Hoefnagels WHL. Hormonal mechanisms of postprandial hypotension. JAm Geriatr Soc . 1991;39:1201-1207. 26. Lipsitz LA, Ryan SM, Parker JA, Freeman R, Wei JY, Goldberger 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.Crossref 27. Peuler JD, Johnson GA. Simultaneous single isotope radioenzymatic assay of plasma norepinephrine, epinephrine, and dopamine. Life Sci . 1977;21:625-636.Crossref 28. Parker JA, Uren RF, Jones AG, et al. Radionuclide left ventriculography with the slant hole collimator. J Nucl Med . 1977;18:848-851. 29. Green MV, Brody WR, Douglas MA, et al. Ejection fraction by count rate from gated images. J Nucl Med . 1978;19:880-883. 30. Diem K, Lentner C, eds. Scientific Tables . Basel, Switzerland: Ciba-Geigy Ltd; 1970:537. 31. Robinson VJB, Smiseth OA, Scott-Douglas NW, Smith ER, Tyberg JV, Manyari DE. Assessment of the splanchnic vascular capacity and capacitance using quantitative equilibrium blood-pool scintigraphy. J Nucl Med . 1990;31: 154-159. 32. SAS Institute. SAS Release 6.04 . Cary, NC: SAS Institute Inc; 1990. 33. Kooner JS, Raimbach S, Watson L, Bannister R, Peart S, Mathias CJ. Relationship between splanchnic vasodilation and postprandial hypotension in patients with primary autonomic failure. J Hypertens . 1989;7:S40-S41.Crossref 34. Lipsitz LA, Bui M, Stiebeling M, McArdle C. Forearm blood flow response to posture change in the very old: non-invasive measurement by venous occlusion plethysmography. J Am Geriatr Soc . 1991:39:53-59. 35. Sneddon JF, Counihan PJ, Bashir Y, Haywood GA, Ward DE, Camm AJ. Impaired immediate vasoconstrictor responses in patients with recurrent neurally mediated syncope. Am J Cardiol . 1993;71:72-76.Crossref 36. Abboud FM, Eckberg DL, Johanssen UJ, Mark AL. Carotid and cardiopulmonary baroreceptor control of splanchnic and forearm vascular resistance during venous pooling in man. J Physiol . 1979;286:173-184. 37. Madkour MA, Fouad-Tarazi MF. Influence of left ventricular diastolic function on vascular and humoral responses to head-up posture in hypertension. Am Heart J . 1989;118:531-538.Crossref 38. Gribbin B, Pickering TG, Sleight P, Peto R. Effect of age and high blood pressure on baroreflex sensitivity in man. Circ Res . 1971;29:424-431.Crossref 39. Ryan SM, Goldberger AL, Ruthazer R, Mietus J, Lipsitz LA. Spectral analysis of heart rate dynamics in elderly persons with postprandial hypotension. Am J Cardiol . 1992;69:201-205.Crossref 40. Esler MD, Hasking GJ, Willet IR, Leonard PW, Jennings GL. Noradrenaline release and sympathetic nervous system activity. J Hypertens . 1985;3:117-129.Crossref 41. Eagle KA, Black HR, Cook EF, Goldman L. Evaluation of prognostic classifications for patients with syncope. Am J Med . 1985;79:455-460.Crossref 42. Linzer M. Syncope: 1991. Am J Med . 1991;90:1-5.Crossref 43. Jonsson PV, Lipsitz LA, Kelley M, Koestner J. Hypotensive responses to common daily activities in institutionalized elderly. Arch Intern Med . 1990;150: 1518-1524.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

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Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1995.00430090087010
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Abstract

Abstract Background: Syncope in older patients may be caused by a variety of disorders, including hypotension, but frequently remains unexplained. Postprandial hypotension is a common disorder of blood pressure regulation in the elderly. Objective: To determine the pathogenic mechanisms and potential role of postprandial hypotension in elderly patients with otherwise unexplained syncope. Methods: We studied 16 elderly patients with unexplained syncope and nine elderly controls. Blood pressure, heart rate, forearm vascular resistance, plasma norepinephrine level, and cardiac and splanchnic blood volumes were measured before and after a 1680-kJ meal. Results: Eight elderly patients with syncope had postprandial hypotension, with a decline in supine mean arterial blood pressure of 17±2 mm Hg after a meal (P<.001). The blood pressure remained unchanged after the meal in the other patients with syncope and the controls. In patients with postprandial hypotension, systemic vascular resistance fell after the meal, while it remained unchanged in the other groups. Heart rate and plasma norepinephrine level increased to a similar extent in all three groups. Forearm vascular resistance increased only in the control subjects. Splanchnic blood volume increased by 26% (P<.01) in patients with syncope who had postprandial hypotension and by 22% (P<.01) in control subjects. Splanchnic blood volume remained unchanged in the patients with syncope without postprandial hypotension. Conclusions: Postprandial hypotension may be an important causative factor in elderly patients with unexplained syncope. The evaluation of syncope in elderly patients should therefore include blood pressure measurements surrounding a meal. Elderly patients with syncope who have postprandial hypotension fail to maintain systemic vascular resistance, probably because of splanchnic blood pooling without a compensatory increase in peripheral vascular resistance.(Arch Intern Med. 1995;155:945-952) References 1. Lipsitz LA. Syncope in the elderly. Ann Intern Med . 1983;99:92-105.Crossref 2. Kapoor WN, Karpf M, Maher Y, Miller MA, Levey GS. Syncope of unknown origin: the need for a more cost-effective approach to its diagnostic evaluation. JAMA . 1982;247:2687-2691.Crossref 3. Kapoor W, Snustad D, Peterson J, Wieand H, Cha R, Karpf M. Syncope in the elderly. Am J Med . 1986;80:419-428.Crossref 4. Lipsitz LA, Pluchino FC, Wei JY, Rowe JW. Syncope in institutionalized elderly: the impact of multiple pathological conditions and situational stress. J Chronic Dis . 1986;39:619-630.Crossref 5. Lipsitz LA, Nyqvist RP, Wei JY, Rowe JW. Postprandial reduction in blood pressure in the elderly. N Engl J Med . 1983;309:81-83.Crossref 6. Westenend M, Lenders JWM, Thien T. The course of blood pressure after a meal: a difference between young and elderly subjects. J Hypertens . 1985;3 ( (suppl 3) ):S417-S419. 7. Lipsitz LA, Fullerton KJ. Postprandial blood pressure reduction in healthy elderly. JAm Geriatr Soc . 1986;34:267-270. 8. Peitzman SJ, Berger SR. Postprandial blood pressure decrease in well elderly persons. Arch Intern Med . 1989;149:286-288.Crossref 9. Jansen RWMM, Lenders JWM, Thien T, Hoefnagels WHL. Antihypertensive treatment and postprandial blood pressure reduction in the elderly. Gerontology . 1987;95:363-368.Crossref 10. 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.Crossref 11. Bellomo G, Santucci S, Aisa G, Parnetti L. Meal-induced arterial blood pressure variations in the elderly. Gerontology . 1988;34:311-314.Crossref 12. Vaitkevicius PV, Esserwein DM, Maynard AK, O'Connor FC, Fleg JL. Frequency and importance of postprandial blood pressure reduction in elderly nursing-home patients. Ann Intern Med . 1991;115:865-870.Crossref 13. Robertson D, Wade D, Robertson RM. Postprandial alterations in cardiovascular hemodynamics in autonomic dysfunctional states. Am J Cardiol . 1981; 48:1048-1052.Crossref 14. Hoeldtke RD, O'Dorisio TM, Boden G. Treatment of autonomic neuropathy with a somatostain analogue SMS 201-995. Lancet . 1986;2:602-605.Crossref 15. Mathias CJ, Da Costa DF, McIntosh CM, et al. Differential blood pressure and hormonal effects after glucose and xylose ingestion in chronic autonomic failure. Clin Sci . 1989;77:85-92. 16. Micieli G, Martignoni E, Cavallini A, Sandrini G, Nappi G. Postprandial and orthostatic hypotension in Parkinson's disease. Neurology . 1987;37:386-393.Crossref 17. Sherman RA, Torres F, Cody RP. Postprandial blood pressure changes during hemodialysis. Am J Kidney Dis . 1988;12:37-39.Crossref 18. Lipsitz LA, Pluchino FC, Wei JY, Minaker ML, Rowe JW. 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.Crossref 19. Jansen RWMM, Hoefnagels WHL. The influence of oral glucose loading on baroreflex function in the elderly. J Am Geriatr Soc . 1989;37:1017-1022. 20. Raimbach SJ, Cortelli P, Kooner JS, Bannister R, Peart WS, Mathias CJ. Prevention of glucose-induced hypotension by the somatostain analogue octreotide (SMS 201-995) in chronic autonomic failure: haemodynamic and hormonal changes. Clin Sci . 1989;77:623-628. 21. Hoeldtke RD, Davis KM, Joseph J, Gonzales R, Panidis IP, Friedman AC. Hemodynamic effects of octreotide in patients with autonomic neuropathy. Circulation . 1991;84:168-176.Crossref 22. Hoeldtke RD, O'Dorisio TM, Boden G. Prevention of postprandial hypotension with somatostatin. Ann Intern Med . 1985;103:889-890.Crossref 23. Jansen RWMM, Peeters TL, Lenders JWM, van Lier HJJ, van't Laar A, Hoefnagels WHL. Somatostatin analogue octreotide (SMS 201-995) prevents the decrease of blood pressure after oral glucose loading in the elderly. J Clin Endocrinol Metab . 1989;68:752-756.Crossref 24. Kuipers HMM, Jansen RWMM, Peeters TL, Hoefnagels WHL. 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. 25. Jansen RWMM, Hoefnagels WHL. Hormonal mechanisms of postprandial hypotension. JAm Geriatr Soc . 1991;39:1201-1207. 26. Lipsitz LA, Ryan SM, Parker JA, Freeman R, Wei JY, Goldberger 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.Crossref 27. Peuler JD, Johnson GA. Simultaneous single isotope radioenzymatic assay of plasma norepinephrine, epinephrine, and dopamine. Life Sci . 1977;21:625-636.Crossref 28. Parker JA, Uren RF, Jones AG, et al. Radionuclide left ventriculography with the slant hole collimator. J Nucl Med . 1977;18:848-851. 29. Green MV, Brody WR, Douglas MA, et al. Ejection fraction by count rate from gated images. J Nucl Med . 1978;19:880-883. 30. Diem K, Lentner C, eds. Scientific Tables . Basel, Switzerland: Ciba-Geigy Ltd; 1970:537. 31. Robinson VJB, Smiseth OA, Scott-Douglas NW, Smith ER, Tyberg JV, Manyari DE. Assessment of the splanchnic vascular capacity and capacitance using quantitative equilibrium blood-pool scintigraphy. J Nucl Med . 1990;31: 154-159. 32. SAS Institute. SAS Release 6.04 . Cary, NC: SAS Institute Inc; 1990. 33. Kooner JS, Raimbach S, Watson L, Bannister R, Peart S, Mathias CJ. Relationship between splanchnic vasodilation and postprandial hypotension in patients with primary autonomic failure. J Hypertens . 1989;7:S40-S41.Crossref 34. Lipsitz LA, Bui M, Stiebeling M, McArdle C. Forearm blood flow response to posture change in the very old: non-invasive measurement by venous occlusion plethysmography. J Am Geriatr Soc . 1991:39:53-59. 35. Sneddon JF, Counihan PJ, Bashir Y, Haywood GA, Ward DE, Camm AJ. Impaired immediate vasoconstrictor responses in patients with recurrent neurally mediated syncope. Am J Cardiol . 1993;71:72-76.Crossref 36. Abboud FM, Eckberg DL, Johanssen UJ, Mark AL. Carotid and cardiopulmonary baroreceptor control of splanchnic and forearm vascular resistance during venous pooling in man. J Physiol . 1979;286:173-184. 37. Madkour MA, Fouad-Tarazi MF. Influence of left ventricular diastolic function on vascular and humoral responses to head-up posture in hypertension. Am Heart J . 1989;118:531-538.Crossref 38. Gribbin B, Pickering TG, Sleight P, Peto R. Effect of age and high blood pressure on baroreflex sensitivity in man. Circ Res . 1971;29:424-431.Crossref 39. Ryan SM, Goldberger AL, Ruthazer R, Mietus J, Lipsitz LA. Spectral analysis of heart rate dynamics in elderly persons with postprandial hypotension. Am J Cardiol . 1992;69:201-205.Crossref 40. Esler MD, Hasking GJ, Willet IR, Leonard PW, Jennings GL. Noradrenaline release and sympathetic nervous system activity. J Hypertens . 1985;3:117-129.Crossref 41. Eagle KA, Black HR, Cook EF, Goldman L. Evaluation of prognostic classifications for patients with syncope. Am J Med . 1985;79:455-460.Crossref 42. Linzer M. Syncope: 1991. Am J Med . 1991;90:1-5.Crossref 43. Jonsson PV, Lipsitz LA, Kelley M, Koestner J. Hypotensive responses to common daily activities in institutionalized elderly. Arch Intern Med . 1990;150: 1518-1524.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: May 8, 1995

References