In patients with obesity, bariatric surgery is effective and sustainable in controlling hypertension and related polypharmacy through 5 years, a new randomized study shows. Carlos A. Schiavon, MD, of the Heart Hospital (hcor), São Paulo, and colleagues, reported these data in a manuscript published Monday online and in the Feb. 13 issue of the Journal of the American College of Cardiology. Obesity rates are expected to grow worldwide over the next decade. By 2025, it is estimated that 21% of women and 16% of men will be obese. Increased amounts of adipose tissue and excessive weight gain give patients higher risk for hypertension. Long-term maintenance and treatment of obesity is a challenge, and bariatric surgery may offer relief. “In clinical practice, obesity is an overlooked condition. As a consequence, there is a frequent failure in approaching obesity as a crucial step for mitigating the risk of important cardiovascular risk factors including hypertension,” said Schiavon in a press release on Monday. The aim of this study was to investigate bariatric surgery and its long-term effects on control of hypertension remission. The GATEWAY study (Gastric bypass to Treat obese Patients With steAdy hYpertension) was a randomized, non-blinded, single-center, investigator-initiated trial comparing bariatric surgery and medical therapies for long-term obesity management, and the present study was an analysis of the 5-year follow-up data. Patients (n=100, 76% women, mean age=43.8 years, body mass index [BMI]= 36.9 ± 2.7kg/m2) with obesity grade 1 or 2, who had hypertension and were using at least two medications, were included in this study. Patients were excluded if they had uncontrolled type 2 diabetes or previous cardiovascular events. The study consisted of two groups: patients assigned to Roux-en-Y gastric bypass (RYGB) with medical therapy (MT) or only MT. At the 1-year and 3-year follow-ups from the GATEWAY trial, bariatric surgery patients had reduced need for antihypertensive medications at both time points, compared with patients who did not receive bariatric surgery (1 year: 12.8% versus 83.7%; 3 years: 11% versus 73%). The primary outcome was a total antihypertensive medication reduction of at least 30% while having a blood pressure <140/90 mm Hg. The primary outcome of the GATEWAY trial was also reassessed at 5 years. The intention-to-treat principle was used for the main analysis. BMI for the RYGB group at 5 years was 28.01 kg/m2 (95% confidence interval [CI]=26.95-29.08 kg/m2) and 36.40 kg/m2 for the MT group (95% CI= 35.28-37.52 kg/m2). Patients in the RYGB group also exhibited a higher rate of medication reduction compared with patients in the MT group (80.7% versus 13.7%; relative risk=5.91; 95% CI=2.58-13.52; p<0.001). The mean number of antihypertensive medications for the RYGB patients was 0.80 (95% CI=0.51-1.09) and 2.97 for MT patients (95% CI=2.33-3.60), p<0.001. Hypertension remission rates were also lower in the RYGB group (2.4% versus 46.9% in the MT group, relative risk=19.66; 95% CI=2.74-141.09; p<0.001). Consistent results were only found in the sensitivity analysis of the completed cases. Resistant hypertension rates were also lower after RYGB compared with patients in the MT group (0% versus 15.2%). Overall, the authors concluded that bariatric surgery can effectively reduce the number of antihypertensive medications taken by patients with obesity- and hypertension. In an accompanying editorial, Michael E. Hall, MD, MSc, Hunter P. Mace, BS, and John E. Hall, PhD, all of the University of Mississippi Medical Center, Jackson, wrote about current hypertension treatments for patients with obesity, and address the need for new management strategies for patients who have obesity and hypertension. “Given that the majority of patients with hypertension are overweight or obese, strategies for preventing excess weight gain and inducing durable weight loss in people with obesity are important for reducing the burden of hypertension and related CV diseases,” the editorialists wrote. Despite limitations of the GATEWAY trial—such as the low patient numbers and the lack of analysis on hard outcomes (mortality or cardiovascular events)—the editorialists discussed the importance of the long-term data provided in this present study. The editorialists concluded, “Durable weight-loss strategies are important for reducing this risk in people with obesity. Novel medical therapies and bariatric surgery are effective ways to treat obesity and related complications.” Sources: Schiavon CA, Cavalcanti AB, Oliveria JD, et al. Randomized Trial of Effect of Bariatric Surgery on Blood Pressure After 5 Years. J Am Coll Cardiol. 2024;83:637-648. Hall ME, Mace HP, Hall JE. Bariatric Surgery for Obesity Hypertension: A Gateway for Durable Blood Pressure Control? J Am Coll Cardiol. 2024;83:649-651. Image Credit: Damian – stock.adobe.com