Postprandial Hypotension: An Underreported Silent Killer in the Aged

Postprandial hypotension is more common than orthostatic hypotension in older adults with dementia with lewy bodies: a cross-sectional study

Cardiovascular autonomic dysfunction is one of the supportive clinical features in dementia with Lewy bodies (DLB). This study aimed to investigate the frequency of postural and postprandial hypotension in people with DLB. The study group comprised 125 patients with DLB (76 females; mean age 78.4 ± 7.1 years) and 122 controls (88 females; mean age 74.4 ± 6.9 years). Postprandial blood pressure changes were assessed by ambulatory 24-hour blood pressure monitorization. Postural blood pressure changes were assessed via the head-up tilt table test. The frequency of postprandial hypotension (PPH) and orthostatic hypotension (OH) was higher in patients with DLB compared to controls (89.4% vs 51.7%; p < 0.001, and 45.5% vs 27.9%; p = 0.004, respectively) whereas the frequency of supine hypertension (SH), and orthostatic hypertension (OHT) was similar. However, SH in non-hypertensive participants was higher in DLB patients than in controls (48.9%, 25.7%; p = 0.035). PPH and OH were independently associated with a diagnosis of DLB (odds ratio [OR]:10.26 confidence interval [CI]%95 3.02-34.82; p < 0.001, and OR:2.22 CI%95 1.2-4.12; p = 0.012, respectively) after adjustment for age, number of medications, use of anti-psychotics drugs, angiotensin receptor blockers, and beta blockers. In conclusion, the study demonstrated that PPH was the most common finding of cardiovascular autonomic dysfunction, followed by OH and SH in older patients with DLB. Given the potential complications of postural blood pressure changes and PPH in such patients, cardiovascular autonomic dysfunction should be evaluated in patients with DLB.

Orthostatic hypotension in the elderly: Prevalence and its management by simple isometric limb tensing exercises

Objective

Orthostatic hypotension (OH), an important cause of falls in the elderly, is grossly underdiagnosed. Our study aimed to determine the prevalence and associated factors of OH among the elderly attending a secondary care hospital. Furthermore, we assessed and compared the effectiveness of simple arm and leg tensing exercises, performed just prior to standing, to mitigate the orthostatic fall in blood pressure (BP) in elderly OH patients.

Materials and Methods

A cross-sectional study screened elderly patients (≥65 years) for OH and recruited them into a randomized controlled trial (CTRI/2020/08/027182) of two parallel groups performing either arm tensing or leg tensing exercises just before standing up. We performed an interim analysis of the ongoing trial using paired t-test for within-group comparisons. Patients identified to have OH based on systolic or diastolic fall in BP were analyzed separately. Chi-square analysis compared the improvement in OH status between the two groups.

Results

Nineteen out of 186 screened elderly patients were diagnosed with OH (10.21%, 95% CI: 7.99-12.43). Arm exercise significantly reduced the orthostatic-induced fall in systolic and diastolic BP, while leg exercise effectively reduced only the systolic fall in BP among patients with OH. The proportion of patients with OH after arm exercise (20%) was significantly lower than after leg exercise (77.8%) (P = 0.023, Fischer's exact test).

Conclusion

We found a 10.21% prevalence of OH in our elderly population. Furthermore, we found that simple isometric arm tensing exercise ameliorates the fall in BP on standing up in OH patients.

Aldosterone Synthase Inhibitors and Dietary Interventions: A Combined Novel Approach for Prevention and Treatment of Cardiovascular Disease

Systemic hypertension (HTN) is the hallmark of cardiovascular disease and the forerunner of heart failure. These associations have been established over decades of research on essential HTN. Advancements in the treatment of patients diagnosed with HTN, consisting of alpha- or beta-adrenergic receptor blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, thiazide, or aldosterone receptor blockers known as anti-mineralocorticoids, in the presence or absence of low sodium salt diets, often fail to control blood pressure adequately to prevent morbidity and mortality. Low sodium diets have had limited success in controlling HTN because low sodium intake is associated with renin-angiotensin-aldosterone system upregulation. Therefore, upregulating aldosterone secretion, sodium, and water retention which, in turn, moves the blood pressure back toward the range of HTN dictated by the baroreceptor reset value, as a compensatory mechanism, especially in resistant HTN. These impediments to blood pressure control in HTN may have been effectively circumvented by the advent of a new class of drugs known as aldosterone synthase inhibitors, represented by baxdrostat. The mechanism of action of baxdrostat as an aldosterone synthase inhibitor demonstrates the inextricable linkage between sodium and blood pressure regulation. Theoretically, combining a low sodium diet with the activity of this aldosterone synthesis inhibitor should alleviate the adverse effect of renin-angiotensin-aldosterone system upregulation. Aldosterone synthesis inhibition should also decrease the oxidative stress and endothelial dysfunction associated with HTN, causing more endothelial nitric oxide synthesis, release, and vasorelaxation. To the best of our knowledge, this is the first systematic review to summarize evidence-based articles relevant to the use of a novel drug (aldosterone synthase inhibitor) in the treatment of HTN and cardiovascular disease. Making the current database of relevant information on baxdrostat and other aldosterone synthase inhibitors readily available will, no doubt, aid physicians and other medical practitioners in their decision-making about employing aldosterone synthase inhibitors in the treatment of patients.