Drugs, surgery both effectively lower blood pressure through weight loss
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Key takeaways:
- Data demonstrate a sustained reduction in BP after bariatric surgery for people with obesity and uncontrolled hypertension.
- Emerging data suggest similar results for people prescribed obesity medications.
Editor's Note: This is part 2 of a three-part Healio Exclusive series on the effect obesity treatments on blood pressure. Part 1 can be viewed here. Part 3 can be viewed here.
Both obesity pharmacotherapy and bariatric surgery offer paths to substantial weight loss for people who struggle with excess weight, and new data suggest there is also an additional bonus benefit for many — a sustained reduction in blood pressure.
In February, two studies published in the Journal of the American College of Cardiology and in Hypertension demonstrated a trend that researchers long suspected or anecdotally reported. For adults with obesity and uncontrolled hypertension, those who either underwent bariatric surgery or were prescribed a potent GLP-1 receptor agonist experienced a marked and sustained reduction in their BP. Select patients even experienced hypertension remission or were able to take fewer antihypertensive medications, potentially paradigm-changing results for a condition that difficult to control with medications.
“In clinical studies, if you reduce body weight in people with obesity and high BP, the BP goes down,” Michael E. Hall, MD, MSc, professor and chair of the department of medicine and director of clinical and population sciences at the Mississippi Center for Clinical and Translational Research at University of Mississippi Medical Center in Jackson, told Healio. “We know from epidemiological studies that there is a strong association between obesity and hypertension. As the body weight goes up over time, the BP goes up over time. Excess weight leads to elevated BPs but treating the weight — and reducing weight — reduces BP.”
Obesity medicines with cardiometabolic benefits
Data from the SURMOUNT-1 study, presented in 2022, showed that nearly all participants with obesity but no diabetes who received tirzepatide (Zepbound, Eli Lilly), an injectable GIP/GLP-1 dual incretin-based agonist, experienced at least 5% weight loss over 72 weeks compared with placebo, with at least 20% weight loss for more than half who received the 15-mg dose.
Data from a planned substudy of the SURMOUNT-1 trial, published in February, showed the drug also reduced 24-hour ambulatory BP for adults with obesity-related hypertension. Researchers said the BP effects were potentially independent of weight loss.
For the prospectively planned substudy published in Hypertension, researchers analyzed data from 600 of the SURMOUNT-1 participants with a BP less than 140 mm Hg/90 mm Hg and stable antihypertensive therapy, if used, including 145 assigned tirzepatide 5 mg, 152 assigned tirzepatide 10 mg, 148 assigned tirzepatide 15 mg, and 155 assigned placebo. This subgroup underwent 24-hour ambulatory BP monitoring (ABPM) at baseline and again at 36 weeks.
Treatment with each tirzepatide dose reduced 24-hour systolic BP at 36 weeks compared with placebo. The placebo-adjusted systolic BP change from baseline was –7.4 mm Hg (95% CI, –10 to –4.7) for tirzepatide 5 mg, –10.6 mm Hg (95% CI, –13.2 to –8) for the 10-mg dose, and –8 mm Hg (95% CI, –10.6 to –5.4) for the 15-mg dose. Results were consistent for both day and nighttime BP.
Participants assigned tirzepatide experienced an increase in heart rate across doses compared with placebo.
“In this analysis, we cannot tease out: Was it just weight loss that led to a drop in BP or was it some other mechanism associated with this GLP-1/GIP?” Luke J. Laffin, MD, co-director of the Center for Blood Pressure Disorders at Cleveland Clinic and a co-investigator of SURMOUNT-1, told Healio. “We do not know that answer. One could make the argument that it is an academic question more than anything else. What we do know is if people are losing 20% of their body weight, which is the ballpark weight loss seen with these GLP-1s, they are going to be on fewer BP medicines. You can almost guarantee that.”
The researchers cautioned that BP was measured only at baseline and one other time point, and measurements were taken only once per hour at night to minimize participant burden. Changes in food intake and 24-hour urine sodium excretion were not assessed.
“If you go in for bariatric surgery, and have Roux-en-Y gastric bypass, within a few months, you will have a dramatic fall in your BP,” George L. Bakris, MD, formerly professor of medicine and director of the American Heart Association-accredited Comprehensive Hypertension Center at the University of Chicago Medicine, told Healio during an interview in April. (Editor’s note: Hypertension expert and longtime editorial board member for Healio George L. Bakris, MD, died June 15, 2024. Read Healio’s tribute to Dr. Bakris here.). “The take-home message is not, ‘Wow, we’ve got drugs now that can reduce body weight and lower BP.’ It is that we have known for at least 80 years that if you reduce your weight, you will reduce your BP. If you cannot [lose weight], these drugs will help you do it.”
Hypertension remission after surgery
Bariatric surgery has proved to be the most effective means of achieving substantial and sustained weight loss, and data show bariatric surgery can improve glycemic response or even induce type 2 diabetes remission. New evidence suggests bariatric surgery may also be an effective treatment for obesity-related hypertension.
Final 5-year data from the GATEWAY trial — the only randomized controlled trial to compare bariatric surgery with medical therapy for BP reduction, use of antihypertensive medications and hypertension remission in people with obesity — demonstrated adults with obesity plus hypertension used fewer BP-lowering medications and were much more likely to experience hypertension remission 5 years after undergoing bariatric surgery compared with medical therapy alone.
The study, published in February in the Journal of the American College of Cardiology, showed that 86.5% of the participants who underwent Roux-en-Y gastric bypass surgery reduced their total antihypertensive medication burden by at least 30% at 5 years, compared with just 12.5% of participants who received antihypertensive medical therapy alone. Additionally, the likelihood of hypertension remission 5 years after gastric bypass was nearly 20-fold higher than for those who received medical therapy only.
“The GATEWAY trial showed that bariatric surgery can be very effective for treatment of patients with obesity and hypertension in the long term,” Carlos Aurelio Schiavon, MD, PhD, FACS, of the Center of Obesity and Bariatric Surgery at Hospital BP in Sao Paulo and a lead investigator for the GATEWAY study, told Healio. “The most important clinical implication of this trial is that we must treat obesity to achieve success when treating patients with cardiovascular diseases such as hypertension.”
Schiavon and colleagues randomly assigned 100 adults with obesity plus hypertension prescribed at least two BP-lowering medications, who had no prior CVD, to Roux-en-Y gastric bypass plus medical therapy or medical therapy alone. The primary outcome was a reduction of at least 30% of total antihypertensive medications while maintaining a BP less than 140 mm Hg/90 mm Hg at 5 years.
Compared with medical therapy, gastric bypass surgery was associated with a higher rate of BP medication reduction (80.7% vs. 13.7%), and the mean number of antihypertensive medications was 2.97 for participants in the medical therapy group and 0.8 for participants in the surgery group.
The rates of hypertension remission were 2.4% in the medical therapy group and 46.9% in the surgery group, and for those in the bariatric surgery group, the rate of apparent resistant hypertension was lower after the procedure (0% vs. 15.2%).
“To move forward, we need randomized trials comparing bariatric surgery with new anti-obesity drugs to demonstrate reduction in CV risk and mortality,” Schiavon told Healio.
Editor’s Note: Part 3 of this Healio Exclusive series will discuss how obesity drugs compare with bariatric surgery and how durable weight loss can reduce CV risk.
We want to hear from you:
Healio wants to hear from you: Have you observed large BP reductions for patients prescribed obesity medications or bariatric surgery? Share your thoughts with Healio by emailing the author at rschaffer@healio.com or posting on X (Twitter) @CardiologyToday. We will contact you if we wish to publish any part of your story.
References:
- Dankner R, et al. JAMA Netw Open. 2024;doi:10.1001/jamanetworkopen.2023.50408.
- de Lemos JA, et al. Hypertension. 2024;doi:10.1161/HYPERTENSIONAHA.123.22022
- Hall ME, et al. J Am Coll Cardiol. 2024;doi:10.1016/j.jacc.2023.11.033.
- Kong G, et al. Obesity. 2023;doi:10.1002/oby.23658.
- Schiavon CA, et al. J Am Coll Cardiol. 2024;doi:10.1016/j.jacc.2023.11.032.
For more information:
Michael E. Hall, MD, MSc, can be reached at mehall@umc.edu; X (Twitter): @UMMC_MCCTR.
Luke J. Laffin, MD, can be reached at laffinl@ccf.org; X (Twitter): @ljlaffin.
Carlos Aurelio Schiavon, MD, PhD, FACS, can be reached at carlos.schiavon@bp.org.br; X (Twitter): @caschiavon.
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