Cardiometabolic Surgery for Treatment of Hypertension?

For many patients with severe obesity, bariatric surgery offers the only viable option for achieving significant long-term weight loss and reducing their dependence on pharmacological treatment of type 2 diabetes mellitus (T2D). In this issue of Hypertension, Schiavon et al provide additional evidence from the GATEWAY trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension) that bariatric surgery is also an effective strategy for reducing the number of antihypertensive medications needed to achieve adequate 24-hour blood pressure (BP) control and for reducing the burden of resistant hypertension in patients with moderate to severe obesity. The pandemic of obesity and associated cardiorenal and metabolic diseases is rapidly becoming our greatest global public health threat. Obesity/overweight accounts for 65% to 75% of the risk for primary (essential) hypertension, the leading cause of cardiovascular mortality worldwide, and ageadjusted hypertension-related deaths have risen in parallel with increasing obesity. Obesity is also the most important risk factor for diabetes mellitus which interacts with hypertension to cause microvascular and macrovascular injury and ultimately damage to target organs, such as the kidneys, heart, and brain. Weight loss and reduced adiposity are, therefore, important therapeutic goals for most patients with hypertension. Although the mainstay for treatment of obesity and associated metabolic disorders continues to be lifestyle therapy aimed at caloric restriction and increased physical activity, most people are unable to achieve and maintain adequate reductions in adiposity by diet and exercise. Several new weight loss medications have been approved for clinical use in the past few years, but they are still less than optimal and not widely used by primary care physicians. Antiobesity drugs often produce only modest weight loss, little or no reduction in BP, and some may have adverse cardiovascular effects. Although many effective antihypertensive drugs are available, adequate BP control is still achieved in <50% of hypertensive patients and those with resistant hypertension are usually overweight or obese. Thus, many obese patients with hypertension are placed on regimens of ≥3 antihypertensive drugs, as well as multiple drugs to control dyslipidemia, insulin resistance and hyperglycemia, inflammation, and other adverse effects of excessive adiposity. Because lifestyle therapy and antiobesity medications are often ineffective in producing satisfactory weight loss lasting >1 year, surgical interventions are increasingly used to achieve long-term reductions in adiposity, as well as to treat cardiometabolic disorders in obese patients. Bariatric surgery has been so successful in producing >70% remission of T2D that it is often called metabolic surgery.5 Bariatric surgery also confers benefits for treatment of hypertension and cardiorenal diseases. In the first major metaanalysis of the impact of bariatric surgery on cardiovascular and metabolic diseases, Buchwald et al reported that Rouxen-Y gastric bypass (RYGB) surgery induced remission of hypertension in ≈75% of the patients. Sarkhosh et al performed a comprehensive analysis of available databases that included human studies of laparoscopic sleeve gastrectomy between 2000 and 2011, and reported that this procedure resulted in complete resolution of hypertension in 58% of patients and that 75% experienced improvement or resolution of their hypertension. Despite this rosy picture, concerns about the long-term durability of antihypertensive effects of bariatric surgery were raised after a report from the Swedish Obese Subjects study which followed 627 obese control subjects and 641 obese patients who underwent RYGB, vertical banded gastroplasty, or gastric banding. The surgically treated group had greater weight loss and lower incidence rates of hypertriglyceridemia, hyperuricemia, and diabetes mellitus than the control group but differences between the groups for incidences of hypertension and hypercholesterolemia were not significant after 10 years. Important limitations of the Swedish Obese Subjects study were that it was not randomized, BP was not a primary outcome, and only 34 of the surgically treated patients who completed the 10-year follow up received RYGB. Subsequent analysis of Swedish Obese Subjects study data included a larger number of RYGB patients and demonstrated average reductions of systolic/diastolic BP of 12.1/7.3 and 5.1/5.6 mm Hg at 2 and at 10 years follow-up, respectively. Additional large meta-analyses have consistently shown benefits of bariatric surgery on BP in obese hypertensive patients with follow-ups varying from 1 to 14 years. Multiple studies have also shown that RYGB or sleeve gastrectomy improves outcomes in patients with heart failure or chronic kidney disease, perhaps at least partly because of improved control of hypertension. The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. From the Department of Physiology and Biophysics (J.E.H., M.E.H.); Department of Medicine (M.E.H.); and Mississippi Center for Obesity Research (J.E.H., M.E.H.), University of Mississippi Medical Center. Correspondence to John E. Hall, Department of Physiology and Biophysics, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216. Email jehall@umc.edu Cardiometabolic Surgery for Treatment of Hypertension?