Finally Diagnosed with Post-Prandial Hypotension

[MikeO]

Over the last year and a half i have been intensely determined on getting a handle on my (nOH/OH) symptoms. This has taken a lot of work on my part and my care team to get under control. From making numerous drug combination/trials and dosage adjustment and going thru cardio rehab we have made measurable progress.

What still eluded us was the continued unexplained syncope episodes. We tried a ILR to catch any arrhythmias and nothing (I had it removed) the 24 hr ambulatory blood pressure monitoring (waste of an effort IMO - half the cuff readings errored out) and only confirmed that my bp is highly laible.

Me not willing to give in to (this is just the way it is) i did a last effort to try and figure out what is going on. So back to basics diagnostics (one change at a time). I made one med timing change (switched my Amlodipine to be taken in the evening) and monitored this for a couple of weeks (nothing bad happened). I am good with the change.

So i then refocused on food. I have long suspected/known food for me is a problem (I have rambled on here many times trying to sort thru this). Very rarely do i feel well after eating and can at times put me on the couch for three hours getting over the discomfort (should have been a red flag) or eating will spark GI flare up which are awful. Back to basics i went with only eating my known safe foods and my GI has been stable. I then tried a suspected GI stressor a acidic hot salsa and my GI flared up right on que. So i am getting help from a dietician soon to help out with my eating woes. Pretty sure i am sensitive to acidic compounds.

But now with getting my GI working again (for now) my syncope still continues. By now not knowing what else to do i dug thru my three years of bp/vitals and notes (guess the devil is in the data) and saw that at times i did record syncope issues after eating but could not show the before and after blood pressures and heart rate (i was still working under being taught to only take my vitals randomly a couple of times a day or when i would have an episode) So i purchased a new blood pressure cuff that is bluetooth enabled and installed an app on my smartphone so that i can actually graph and show (notes) of my vitals. I then became very aggressive recording data and notes (from when i get up in the morning, when i take meds, after a shower and especially before i ate and then 30 mins to 1-2 after) this over time started showing a distinct pattern that my blood pressure would drop after the meal (very visible on the graph) that correlated with my notes. What a game changer!

To be honest i would have never guessed food could affect bp's in folks like it does with me. I sure i have seen the term post-prandial hypotension before but never put any thought into it as the guidelines for managing (nOH/OH) that i recall reading never mentioned it nor has the food induced syncope come up with the diagnostics my care team has done (sigh). I do get the feeling post-prandial hypotension is not taught in the mainstream health care and have since read several articles that mention just this.

Since i have been able to present my care team with the results of my aggressive vital monitoring and get a definitive diagnosis for post-prandial hypotension. If not just knowing the cause of my syncope as being a relief i now have some path i can act on to make a differance.

I hope this write up helps other folks.

Partial note from my Doctor:

This pattern of decrease in blood pressure within 2 hours of eating is consistent with post-prandial hypotension, not uncommon in patients with orthostatic hypotension.    

    

[GasconAlex]

I'm surprised that the ambulatory BP measurements had so many errors. When I had it done there were only a couple of errors in the readings. The only issue I had was the inconvenience of the cuff inflating every 10 minutes (20 during 'sleep'). 

From what I understand with post prandial hypotension it's the blood being directed to the gut to process food that causes the syncope. I would guess that the same advice that I have (in order to try to prevent further weight loss) might well work which is to split meals up as much as possible to be small and frequent.

Hopefully a 'food management technique' will help solve / reduce this problem for you.

[Pistol]

@MikeO I really admire your tenacity! Good job! One thing - I do not suffer prom postprandial Hypotension but also become highly symptomatic after a meal. I agree with @GasconAlex - small and frequent snacks/meals have been a game changer for me! I will eat every 2 hours and avoid large meals, this has overall minimized syncopal episodes as well as GI distress. 

[Sushi]

@MikeO Have you tried an abdominal binder? It helps me with post-meal hypotension as it prevents (to a degree) splanchnic pooling.

[MikeO]

@SushiYes i do have a abdominal binder. I really felt it did not help with me and is a bit uncomfortable to wear. Since i bought it last summer i lost about 10 lbs (from not wanting to eat) sure the weight loss helps regardless. If i do try a binder again i think i will get one custom fitted (might work out better)

[MikeO]

Well i did a bit more looking into postprandial hypotension (just trying to understand it) and if there is any diet suggestions out on the web outside of the blanket eat low carbs (not much out there).

I did find an study that suggested that the more high carb content foods will break down into higher glucose levels and is a possible mechanism for the pooling of blood. I have read that some of the testing for this will use a known high carb meal or a high glucose liquid to perform the test. so kinda led me into looking at the glucose values of carbs that are broken down in the digestive tract (did find material on this) more aimed at diabetics but data is out in the wild.

I was surprised to find that eating instant oatmeal has a high glycemic value as well as a high glycemic load (instant oatmeal has been a stressor for me). I really hope the dietitian i am seeing next week is knowledgeable. 

Below are some reference material i have looked at.

Glycemic value/load of some foods

https://extension.oregonstate.edu/sites/default/files/documents/1/glycemicindex.pdf

Study i referenced above

https://www.hindawi.com/journals/jar/2010/243752/

In this study, the subjects ate a continental breakfast, in which the release of glucose is quite constant whereas other studies used standardized liquid meals, in which the release of glucose is rapid. We chose a standardized continental breakfast as being more representative of the normal situation. Moreover, we hypothesize that differences in the severity of PPH observed with high and low carbohydrate-containing meals can be explained by differences in the rate of glucose uptake rather than by differences in the total number of calories consumed, a hypothesis that is supported by the findings of O’Donovan et al. [16]. They found that the fall in systolic blood pressure was greater with a higher rate of glucose delivery into the duodenum. Despite the probably relatively low rate of glucose delivery with our continental breakfast, a large proportion of our subjects developed PPH.

[MikeO]

21 hours ago, DysautonmiaMatt said:

Good you got a diagnosis. I would guess eating whole foods like veggies, eggs/protein and healthy fats like avocados could help - only water to drink might help. I read a long time ago never start off the day with carbs. It sends glucose too high and its a roller coaster rest of day. I eat no carbs for breakfast and never feel bad after eating it. I make all my meals so I control what is in them. The standard American diet is far from healthy.  

Not sure what to think. I have done ok with a couple of hard boiled eggs and yogurt in the morning. I have read many times that carbs don't sit well with Dysautonomic folks.

I did dig up a comprehensive Glycemic index/Glycemic Load database out of Australia. https://glycemicindex.com/gi-search/

As well as more possible causes of postprandial hypotension.

https://pubmed.ncbi.nlm.nih.gov/7825766/#:~:text=Possible contributors include inadequate sympathetic,vasodilation%2C and release of vasodilatory

 Possible contributors include inadequate sympathetic nervous system compensation for meal-induced splanchnic blood pooling; impairments in baroreflex function; inadequate postprandial increases in cardiac output; and impaired peripheral vasoconstriction, insulin-induced vasodilation, and release of vasodilatory gastrointestinal peptides. Although caffeine is often recommended as treatment for postprandial hypotension

[MTRJ75]

2 hours ago, MikeO said:

Not sure what to think. I have done ok with a couple of hard boiled eggs and yogurt in the morning. I have read many times that carbs don't sit well with Dysautonomic folks.

I did dig up a comprehensive Glycemic index/Glycemic Load database out of Australia. https://glycemicindex.com/gi-search/

As well as more possible causes of postprandial hypotension.

https://pubmed.ncbi.nlm.nih.gov/7825766/#:~:text=Possible contributors include inadequate sympathetic,vasodilation%2C and release of vasodilatory

 Possible contributors include inadequate sympathetic nervous system compensation for meal-induced splanchnic blood pooling; impairments in baroreflex function; inadequate postprandial increases in cardiac output; and impaired peripheral vasoconstriction, insulin-induced vasodilation, and release of vasodilatory gastrointestinal peptides. Although caffeine is often recommended as treatment for postprandial hypotension

I have LOTS of trouble with carbs. Especially gluten containing ones. 

That's kind of mind-blowing, considering the other issues caffeine can cause with an off the rails ANS. 

[MikeO]

56 minutes ago, MTRJ75 said:

That's kind of mind-blowing, considering the other issues caffeine can cause with an off the rails ANS.

I know. When i first met my specialist she said to hold off on the Coffee (Caffeine). Since this diagnosis she retracted that and suggests a cup of Coffee with meals as long as i can tolerate it which i can as well as the smaller more frequent low carb meals and trying a glass of water 15 mins before eating. (Drinking a whole pot is a another story) 

[MikeO]

On 9/3/2022 at 6:35 AM, MikeO said:

I do get the feeling post-prandial hypotension is not taught in the mainstream health care and have since read several articles that mention just this.

Well i got this one right. I was just in for my 6 mo check up with my PCP and brought up my specialists post-prandial finding. He had not heard of it. He did look it up on the UpToDate.com website. I also showed him my blood pressure app that ultimately got me the diagnosis. He was impressed. He did print me off a copy of the UpToDate article (very informative)   

[MikeO]

15 hours ago, DysautonmiaMatt said:

I have been feeling better now that Lexapro is a drug of the past for me - NEVER again.

Glad to hear you were able to get off the Lexapro. I am sure you are feeling better.

[MikeO]

Update: I did see a UW Madison nutritionist today. We did talk extensively. She did order a oral glucose tolerance test (they want to rule in or out issues). @DysautonmiaMattyou may be on the right track.

Print out she gave me sites (postprandial syndrome and reactive hypoglycemia) I think @JennKaywas looking into this.

To my surprise she was also aware of Dysautonomic disorders (POTS etc...) when i described my Whooshing episodes she knew exactly what i was talking about.   

We did make some diet modifications. I do go back in three weeks (she is very interested in me)

Below is the sample diet she ave me. Hope this helps someone.

[MikeO]

16 minutes ago, DysautonmiaMatt said:

That diet suggestion is full of carbs but not a surprise.

Yeah there is more to this than meets the eye. One does need carbs for energy etc... just like fat is also required along with salt, water and whatever else. Take away in our discussion is to eat comperal amount of protein with the carbs being the mixture of protein and carbs will break down more slowly than just a carb by itself.

Sure i have more coming to the story soon.  

[JennKay]

@MikeO -- Am curious to see how it works for you too! Yes, if I eat any amount of refined sugar, like anything more than what is in a handful of M&Ms or something similar, my sugar spikes then crashes. Not as bad as when I was preggers, but still enough for me to notice it. I usually have to go eat some protein to correct it. Large amounts of sugar just aren't worth it anymore...unfortunately!

[MTRJ75]

I thought the same thing about the carbs as I read that dietary suggestion. More and more horrified as I went down the list. There are obvious replacements for them and not all carbs are bad, but you still may want to stay away from the gluten/bread/nightshade stuff. 

[MikeO]

1 hour ago, MTRJ75 said:

nightshade stuff.

Dietician did speak to the nightshade foods with me. they are banned on my chart.

[MikeO]

Example of my blood pressure drop after eating breakfast. I started to feel a little ill about 15 mins after the meal and like right on queue my bp went down abou an hour later. While the drop (bp pressures) was not enough to make me lightheaded. if i would have eaten when my numbers were 110 to start i would have had a problem.