Postprandial Hypotension—Methods for the Evaluation and Management

Postprandial hypotension (PPH) is a common but underrecognized condition in older adults that affects nearly half of the population and is frequently associated with autonomic dysfunction. Unlike orthostatic hypotension (OH), PPH often presents with sleepiness and syncope. Its prevalence and severity are influenced by meal composition, particularly carbohydrate content, and the time of day, with morning meals posing a greater risk. Its pathophysiology involves splanchnic blood pooling, altered gastric emptying, impaired baroreflex function, and intestinal peptide activity, including those of glucagon-like peptide (GLP)-1 and GLP-2. Despite its clinical significance, PPH lacks standardized diagnostic criteria. Conventional blood pressure (BP) measurements, ambulatory BP monitoring (ABPM), and home BP monitoring (HBPM) have been used to detect PPH, with ABPM offering continuous data and HBPM providing practical position-controlled assessments. However, variability in test meals and measurement protocols limits consistency across studies. Management primarily involves lifestyle modifications, such as premeal water intake, smaller and low-carbohydrate meals, and postprandial exercise. Pharmacological interventions, including acarbose, which targets PPH associated with autonomic dysfunction, may be considered in select cases. Emerging therapies involving gut peptides, such as GLP-1 analogs and DPP-4 inhibitors, show promise, especially in patients with α-synucleinopathies. PPH frequently coexists with OH and supine hypertension, complicating diagnosis and treatment. Screening for positional BP dysregulation and tailoring interventions for individual autonomic profiles are essential. Given its association with cardiovascular events and mortality, the improved recognition and management of PPH are critical in geriatric care.