Meal-induced blood pressure variation and cardiovascular mortality in ambulatory hypertensive elderly patients: preliminary results

Systematic review and meta-analysis examining the relationship between postprandial hypotension, cardiovascular events, and all-cause mortality

BACKGROUND

Postprandial hypotension (PPH) has been reported to be associated with syncope, falls, adverse cardiovascular outcomes, and increased all-cause mortality. It has been reported to have an incidence as high as 30% in the elderly and persons with diabetes. We therefore performed a meta-analysis to determine the relation of PPH with cardiovascular disease (CVD) events and all-cause mortality.

OBJECTIVES

Our objective was to conduct a systematic review and meta-analysis of cohort and cross-sectional studies to determine the association of PPH with CVD and all-cause mortality.

METHODS

We searched the databases MEDLINE, EMBASE, and Cochrane library up to 13 April 2022 for prospective cohort and cross-sectional studies that examined the association of PPH with CVD outcomes and all-cause mortality. Data were analyzed using the generic inverse variance method with a random-effects model. Grading of Recommendations, Assessment, Development, and Evaluation approach assessed the certainty of evidence.

RESULTS

Seven studies that included 2389 participants met our inclusion criteria. PPH was associated with each outcome individually, including increased all-cause mortality, total CVD, CVD mortality, and stroke. CVD outcomes and all-cause mortality combined were also associated with PPH (RR: 1.52; 95% CI: 1.05, 2.18; P = 0.03; I2 = 77%). The certainty of evidence was graded as very low due to significant heterogeneity and the limited number of studies.

CONCLUSIONS

This assessment indicates an association of PPH with CVD and all-cause mortality. Further studies are required to improve CVD and mortality estimates, but the potential seriousness of CVD and all-cause mortality as outcomes of PPH justifies more screening, diagnosis, and research.

The relationship between glycemic variability and blood pressure variability in normoglycemic normotensive individuals

BACKGROUND AND AIM

Glycemic fluctuations around a mean glucose level, referred as glycemic variability and blood pressure variability (BPV) are considered as independent risk factors for cardiovascular diseases, all-cause mortality, and cardiovascular disease-mortality. With this background in mind, we aimed to investigate the association between glycemic variability and BPV and their association in normoglycemic and normotensive individuals.

MATERIALS AND METHOD

Twenty-seven normotensive normoglycemic individuals were recruited. Twenty-four hour Holter devices were utilized to measure ambulatory blood pressure (BP) while continuous glucose monitoring (CGM) devices were applied to measure glycemic variability simultaneously to the subjects. These devices were kept on for 48 h. For BP recordings, daytime, nighttime, and 24-h BP determinations, their mean and SD were calculated. From CGM measurements, mean blood glucose (MBG), SD of blood glucose, the mean amplitude of glycemic excursions (MAGE), the mean of daily differences (MODD), coefficient of variation (correction of variability for the MBG), and daytime and nighttime blood glucose were determined.

RESULTS

The mean age of the subjects was 23.8 ± 2.7 years and 66% were women (18/27). In the correlation analysis between glycemic variability parameters and BPV parameters, SD of 24-h SBP was correlated with the SD of MBG (r = 0.52, P = 0.006), MAGE (r = 0.49, P = 0.009), and MODD (r = 0.46, P = 0.015). SD of daytime SBP was correlated with, MAGE (r = 0.42, P = 0.03) and MODD (r = 0.43, P = 0.02).

CONCLUSION

We report correlation between glycemic variability and BPV variables in normoglycemic and normotensive healthy individuals.

Postprandial Hypotension as a Risk Factor for the Development of New Cardiovascular Disease: A Prospective Cohort Study with 36 Month Follow-Up in Community-Dwelling Elderly People

Postprandial hypotension (PPH) is common among the elderly. However, it is unknown whether the presence of PPH can predict the development of new cardiovascular disease (CVD) in the elderly during the long-term period. This study aimed to prospectively evaluate the presence of PPH and the development of new CVD within a 36 month period in 94 community-dwelling elderly people without a history of CVD. PPH was diagnosed in 47 (50.0%) participants at baseline and in 7 (7.4%) during the follow-up period. Thirty participants (31.9%) developed new CVD within 36 months. We performed a time-dependent Cox regression analysis with PPH, hypertension, diabetes, and body mass index (BMI) as time-varying covariates. In the univariate analyses, the presence of PPH, higher BMI, hypertension, diabetes mellitus, and higher systolic and diastolic blood pressure were associated with the development of new CVD. The multivariate analysis indicated that the relationship between PPH and the development of new CVD remained (adjusted hazard ratio 11.18, 95% confidence interval 2.43-51.38, p = 0.002) even after controlling for other variables as covariates. In conclusion, the presence of PPH can predict the development of new CVD. Elderly people with PPH may require close surveillance to prevent CVD.

Acute Effects of Nutritive and Non-Nutritive Sweeteners on Postprandial Blood Pressure

Postprandial hypotension (PPH) is under-recognised, but common, particularly in the elderly, and is of clear clinical importance due to both the independent association between PPH and an increase in mortality and lack of effective management for this condition. Following health concerns surrounding excessive consumption of sugar, there has been a trend in the use of low- or non-nutritive sweeteners as an alternative. Due to the lack of literature in this area, we conducted a systematic search to identify studies relevant to the effects of different types of sweeteners on postprandial blood pressure (BP). The BP response to ingestion of sweeteners is generally unaffected in healthy young subjects, however in elderly subjects, glucose induces the greatest decrease in postprandial BP, while the response to sucrose is less pronounced. The limited studies investigating other nutritive and non-nutritive sweeteners have demonstrated minimal or no effect on postprandial BP. Dietary modification by replacing high nutritive sweeteners (glucose, fructose, and sucrose) with low nutritive (d-xylose, xylitol, erythritol, maltose, maltodextrin, and tagatose) and non-nutritive sweeteners may be a simple and effective management strategy for PPH.

Autonomic dysfunction: Diagnosis and management

The autonomic nervous system is designed to maintain physiologic homeostasis. Its widespread connections make it vulnerable to disruption by many disease processes including primary etiologies such as Parkinson's disease, multiple system atrophy, dementia with Lewy bodies, and pure autonomic failure and secondary etiologies such as diabetes mellitus, amyloidosis, and immune-mediated illnesses. The result is numerous symptoms involving the cardiovascular, gastrointestinal, and urogenital systems. Patients with autonomic dysfunction (AUD) often have peripheral and/or cardiac denervation leading to impairment of the baroreflex, which is known to play a major role in determining hemodynamic outcome during orthostatic stress and low cardiac output states. Heart rate and plasma norepinephrine responses to orthostatic stress are helpful in diagnosing impairment of the baroreflex in patients with orthostatic hypotension (OH) and suspected AUD. Similarly, cardiac sympathetic denervation diagnosed with MIBG scintigraphy or ¹⁸F-DA PET scanning has also been shown to be helpful in distinguishing preganglionic from postganglionic involvement and in diagnosing early stages of neurodegenerative diseases. In this chapter, we review the causes of AUD, the pathophysiology and resulting cardiovascular manifestations with emphasis on the diagnosis and treatment of OH.

Positive Effects of Tomato Paste on Vascular Function After a Fat Meal in Male Healthy Subjects

Tomato consumption has been recently associated with a reduced incidence of cardiovascular disease (CVD). The aim of this study was to test whether a seven-day period of tomato paste purèe (tomato paste, TP) supplementation could improve some haemodynamic parameters in healthy volunteers before and after a standardized fat meal (FM).

METHODS AND RESULTS

Nineteen healthy male volunteers participated in a randomized, single-blind (operator) crossover study. Participants maintained low fiber diets (LFD) during the study periods. They were randomized either to a LFD and TP arm (80 g of TP/day) for seven-days, or to a control arm (LFD-only) with a two-week washout period. Flow Mediated Dilatation and other morpho-functional vascular indices were measured by ultrasound. Stiffness Index and Reflection Index were estimated by digital photo-plethysmography. All these parameters were measured one h before and two and 3.5 h after the FM. The difference in Stiffness Index was increased in the LFD and TP + FM-arm, as compared to the LFD-only + FM arm at both two and 3.5 h points. After the FM, in both arms, at two h, we observed a reduction in the Reflection Index and an increase in heart rate. Interestingly, only in the LFD and TP + FM-arm, some haemodynamic changes were detectable at two h; notably, there was an increase in brachial artery diameter and a reduction in diastolic blood pressure (BP).

CONCLUSIONS

TP has no effect on Flow Mediated Dilatation but acutely modifies some haemodynamic parameters triggered by FM, suggesting possible haemodynamic beneficial effects in people consuming tomatoes.

Postprandial hypotension in older people receiving tube feeding through gastrostomy

AIM

Postprandial hypotension (PPH) is recognized as a clinical problem, constituting a potential risk for cerebral and cardiovascular events, as well as mortality. The present study was designed to test the hypothesis that PPH is prevented by slowing the infusion rate of enteral nutrition through tube feeding and by avoiding the administration of antihypertensive drugs just before the start of tube feeding.

METHODS

Participants were older people receiving tube feeding through gastrostomy who used a geriatric health services facility (n = 12; mean age 79.8 years). Changes in blood pressure during and after enteric nutrient infusion lasting for 1 or 2 h were investigated with or without the administration of antihypertensive drugs just before the start of tube feeding.

RESULTS

When enteric nutrient was infused for 1 h, after the administration of antihypertensive drugs, nine of 12 participants showed PPH with a maximal reduction in systolic blood pressure of 37.6 ± 6.5 mmHg. Although PPH was not prevented by avoiding drug administration before infusion (maximal blood pressure reduction 30.2 ± 5.0 mmHg) or by extending the infusion time to 2 h (26.5 ± 7.5 mmHg), the combination of the two actions prevented PPH and reduced the postprandial fall in systolic blood pressure to 17.6 ± 5.8 mmHg.

CONCLUSIONS

The prevalence of PPH in older people receiving tube feeding was 75%. Slowing the enteric nutrient infusion rate combined with avoiding antihypertensive drugs just before the infusion was useful for preventing PPH. Geriatr Gerontol Int 2018; 18: 1474-1478.

Postprandial effect of breakfast glycaemic index on vascular function, glycaemic control and cognitive performance (BGI study): study protocol for a randomised crossover trial

Background

Postprandial glycaemic response affects cognitive and vascular function. The acute effect of breakfast glycaemic index on vascular parameters is not sufficiently known. Also, the influence of breakfasts with different glycaemic index on cognitive performance has been mostly studied in children and adolescents with varying results. Therefore, the purpose of this study is to analyse the postprandial effect of high and low glycaemic index breakfasts on vascular function and cognitive performance and their relationship with postprandial glycaemic response in healthy young adults.

Methods/design

This is a crossover clinical trial targeting adults (aged 20–40 years, free from cardiovascular disease) selected by consecutive sampling at urban primary care health clinics in Salamanca (Spain). Each subject will complete three interventions with a washout period of one week: a control condition (consisting of water); a low glycaemic index breakfast (consisting of dark chocolate, walnuts, yogurt and an apple, with an overall glycaemic index of 29.4 and an energy contribution of 1489 kJ); and a high glycaemic index breakfast (consisting of bread, grape juice and strawberry jam, with an overall glycaemic index of 64.0 and an energy contribution of 1318 kJ). The postprandial effect will be assessed at 60 and 120 minutes from each breakfast including blood sampling and cognitive performance evaluations. Measurements of arterial stiffness and central haemodynamic parameters will be taken at –10, 0, 15, 30, 45, 60, 75, 90, 105 and 120 minutes.

Discussion

The differences in postprandial glycaemic response due to breakfast glycaemic index could affect vascular parameters and cognitive performance with important applications and implications for the general population. This could provide necessary information for the establishment of new strategies in terms of nutritional education and work performance improvement.

Trial registration

ClinicalTrials.gov: NCT02616276. Registered on 19 November 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1649-x) contains supplementary material, which is available to authorized users.

Predialysis hypotension is not a predictor for mortality in long-term hemodialysis patients: insight from a single-center observational study

Introduction

Predialysis hypotension has been noted to be a predictor of mortality in hemodialysis (HD) patients. Previous studies evaluating the impact of predialysis hypotension on the mortality of HD patients did not exclude patients with diabetes mellitus (DM) or cardiovascular disease.

Methods

Eight hundred and sixty-six patients on maintenance HD were recruited. Clinical parameters were recorded and subjected to the analysis of predictors of predialysis hypotension and mortality.

Results

Multivariate logistic regression analyses indicated that DM (odds ratio [OR]: 0.439, P=0.002), hypertension history (OR: 0.634, P=0.022), Kt/V Daugirdas (OR: 2.545, P=0.001), anuria (OR: 2.313, P=0.002), serum phosphate (OR: 0.833, P=0.010), and serum triglyceride (OR: 1.002, P=0.012) were associated with predialysis hypotension. Multivariate Cox regression analysis showed that age (P<0.001), male sex (P=0.029), anuria (P=0.004), and DM (P=0.011) were associated with higher probability of 24- and 36-month mortality. Predialysis hypotension was not associated with higher probability of 12-, 24-, and 36-month mortality.

Conclusion

Predialysis hypotension is not a predictor of 12-, 24-, and 36-month survival in patients without DM and with higher dialysis adequacy.

Utility of home blood pressure monitoring to evaluate postprandial blood pressure in treated hypertensive patients

Postprandial hypotension, defined as a fall in systolic blood pressure (SBP) of 20 mmHg or greater within 2 hours after a meal, is a risk factor for stroke, coronary events and mortality. The clinical suspicion is typically raised by episodes of postprandial syncope or falls, whereas asymptomatic postprandial hypotension is mostly neglected. The magnitude of the postprandial fall in SBP, as detected by 24-hour recording in apparently healthy middle-aged to elderly subjects, was proportional to the severity of the silent cerebrovascular damage. Postprandial hypotension can also be detected by self-measured blood pressure before and within 2 hours after meals using automatic devices. The review highlights the value of home blood pressure monitoring (HBPM) as a screening test for asymptomatic postprandial hypotension in hypertensive patients. Using a HBPM protocol that included duplicated blood pressure measurements before and after three consecutive lunches, we detected unsuspected postprandial hypotension in 27.4% of the 230 hypertensive patients screened. The prevalence of postprandial hypotension was 13.2% in controlled and 42.2% in uncontrolled hypertensive patients (p < 0.001), raising the dilemma of further lowering blood pressure in the setting of postprandial hypotension. The inclusion of preprandial and postprandial measurements in the protocol of HBPM is useful to identify hypertensive patients with postprandial hypotension and may guide adjustments in antihypertensive treatment according to postprandial blood pressure.

Effects of the amount of rice in meals on postprandial blood pressure in older people with postprandial hypotension: a within-subjects design

AIMS AND OBJECTIVES

To determine the effect of the amount of rice carbohydrates consumed during mealtime on the extent of decrease in postprandial blood pressure in older people with postprandial hypotension.

BACKGROUND

The incidence of postprandial hypotension is as high as 74% in older people with hypertension.

DESIGN

A within-subjects repeated measures design was used.

METHODS

Thirty-nine older people in nursing homes received a full serving and a half-serving of rice on two separate days, in random order blood pressure and heart rate were measured before each meal and every 15 minutes for a total of 120 minutes after each meal. Data were analysed using repeated measures analysis of variance and the paired t-test with a Bonferroni adjustment using IBM spss version 19.0.

RESULTS

The control and intervention conditions yielded significantly different patterns in systolic blood pressure and diastolic blood pressure. Postprandial hypotension was less frequent under the intervention condition; however, decrease in rice intake did not significantly affect heart rate.

CONCLUSION

Reducing the amount of rice intake per meal prevents postprandial blood pressure decreases in the older people. Small and frequent meals with decreased carbohydrate content are recommended to prevent postprandial hypotension and its complications in the older people.

RELEVANCE TO CLINICAL PRACTICE

Patients, dieticians and caregivers of older patients should be aware of the importance of diet, especially of decreasing the amount of carbohydrate in a meal. Smaller and more frequent meals are recommended for older people to slow gastric emptying.

Effects of guar gum ingestion on postprandial blood pressure in older adults

OBJECTIVES

The aim of this study was to investigate the effects of guar gum on postprandial blood pressure in older people.

DESIGN

A randomized, double-blind, placebo-controlled, cross-over design.

SETTING

Community senior centers in B city, South Korea.

PARTICIPANTS

Twenty-two older female adults aged 67 to 88 with postprandial hypotension.

INTERVENTION

The participants were randomly assigned to guar gum (semi-fluid food with 9 gram) or placebo intervention during the first treatment phase. After a washout period of 1 week, the two interventions were switched to the other in the second treatment phase.

MEASUREMENTS

Blood pressure was measured during both phases before having a meal and every 15 minutes during 120 minutes after a meal with automated sphygmomanometer.

RESULTS

Change in systolic blood pressure (SBP) over time was significantly different between guar gum and placebo groups (F=4.07, p=0.001). Compared with placebo group, guar gum group had significantly low prevalence of postprandial hypotension (PPH) (guar gum group=18.2% vs. placebo group=72.7%; χ² =13.20, p<0.001). It also had significant difference in change of diastolic blood pressure (DBP) over time between guar gum and placebo groups (F=2.49, p=0.027).

CONCLUSION

This findings show that guar gum could be effective on postprandial drops in blood pressure in older female adults.

Inter-arm blood pressure difference in hospitalized elderly patients--is it consistent?

Inter-arm blood pressure difference (IAD) is recognized as a risk factor for cardiovascular mortality. Its reproducibility in the elderly is unknown. The authors determined the prevalence and reproducibility of IAD in hospitalized elderly patients. Blood pressure was measured simultaneously in both arms on two different days in elderly individuals hospitalized in a geriatric ward. The study included 364 elderly patients (mean age, 85±5 years). Eighty-four patients (23%) had systolic IAD >10 and 62 patients (17%) had diastolic IAD >10 mm Hg. A total of 319 patients had two blood pressure measurements. Systolic and diastolic IAD remained in the same category in 203 (64%) and 231 (72%) patients, respectively. Correlations of systolic and diastolic IAD between the two measurements were poor. Consistency was not affected by age, body mass index, comorbidities, or treatment. IAD is extremely common in hospitalized elderly patients, but, because of poor consistency, its clinical significance in this population is uncertain.

Postprandial hypotension: a systematic review

BACKGROUND

Postprandial hypotension (PPH) is an important clinical problem, which has received inappropriately little attention.

METHODS

A systematic search of the databases PubMed, Embase, Cochrane Library, and Web of Knowledge, from their inception to the present time, was conducted to identify studies relevant to the epidemiology, pathophysiology, and/or management of PPH.

RESULTS

A total of 417 full-text papers were retrieved from database searching and, following screening, 248 were retained. Of these, 167 papers were considered eligible for inclusion.

CONCLUSIONS

PPH occurs commonly in older people and represents a major cause of morbidity. Although the pathophysiology of PPH remains poorly defined, diverse factors, including impairments in sympathetic and baroreflex function, release of vasodilatory peptides, the rate of small intestinal nutrient delivery, gastric distension, and splanchnic blood pooling, appear important. Current pharmacologic and nonpharmacologic management is suboptimal. Research into the pathophysiology of PPH represents a priority so that management can be targeted more effectively.

Postprandial hypotension detected through home blood pressure monitoring: a frequent phenomenon in elderly hypertensive patients

Postprandial hypotension (PPH) is a frequently under-recognized entity associated with increased morbidity and mortality. The prevalence of PPH detected through home blood pressure monitoring (HBPM) is unknown. To determine the prevalence and clinical predictors of PPH in hypertensive patients assessed through HBPM. Hypertensive patients of 18 years or older underwent home blood pressure (BP) measurements (duplicate measurements for 4 days: in the morning, 1 h before and 1 h after their usual lunch, and in the evening; OMRON 705 CP). PPH was defined as a meal-induced systolic BP decrease of ≥20 mm Hg. Variables identified as relevant predictors of PPH were entered into a multivariate logistic regression analysis. In total, 230 patients were included in the analysis, with a median age of 73.6 (interquartile range 16.9) years, and 65.2% were female. The prevalence of PPH (at least one episode) was 27.4%. Four variables were independently associated with PPH: age of 80 years or older (odds ratio (OR) 3.45, 95% confidence interval (CI) 1.35-8.82), body mass index (BMI) (OR 0.88, 95%CI 0.81-0.96), office systolic BP (OR 1.03, 95%CI 1.01-1.05) and a history of cerebrovascular disease (OR 3.29, 95%CI 1.03-10.53). PPH after a typical meal is a frequent phenomenon that can be detected through HBPM. Easily measurable parameters in the office such as older age, higher systolic BP, lower BMI and a history of cerebrovascular disease may help to detect patients at risk of PPH who would benefit from HBPM.