GATEWAY: Bariatric Surgery Effective to Control Hypertension, Polypharmacy in Patients With Obesity

Bariatric surgery is effective in controlling hypertension (HTN) and polypharmacy in patients with obesity, according to results from the GATEWAY clinical trial published Feb. 5 in JACC.

Carlos A. Schiavon, MD, et al., conducted the randomized clinical trial to determine the long-term effects of bariatric surgery on HTN and remission. The trial included 100 patients (76% women, age 43.8 years, body mass index (BMI), 36.9 kg/m2) with obesity grade 1 or 2 plus HTN using at least two medications, The study excluded patients with previous cardiovascular events or poorly controlled type 2 diabetes.

In the study, patients were randomized to either Roux-en-Y gastric bypass (RYGB) plus medical therapy (MT) or MT alone. The primary endpoint was a reduction of at least 30% of the total antihypertensive medications while maintaining blood pressure levels <140/90 mm Hg at five years, using the intention-to-treat principle.

Results showed that at five years, BMI was 36.40 kg/m2 for MT alone and 28.01 kg/m2 for RYGB plus MT (p<0.001). The rate of polypharmacy reduction was higher with RYGB plus MT vs. MT alone (80.7% vs 13.7%; relative risk, 5.91; 95% CI, 2.58-13.52; p<0.001), and remission rates for HTN were higher (2.4% vs. 46.9%). The rate of apparent resistant HTN was lower after RYGB (0% vs. 15.2%).

The authors write that, “Bariatric surgery is a highly effective and durable way to manage HTN in patients with grade 1 and 2 obesity. Long-term outcome studies of larger populations are needed to compare bariatric surgery to other weight loss strategies for patients with obesity and other cardiovascular comorbidities.”

In a related editorial comment, Michael E. Hall, MD, MSc, FACC, Hunter P. Mace, BS, and John E. Hall, PhD,  write that “The GATEWAY trial provides important long-term RCT data showing the beneficial five year impact of RYGB on weight loss and [blood pressure] control. Further studies assessing the threshold (mean body mass index vs. other measures of adiposity) for bariatric surgery in people with obesity, optimal timing of bariatric surgery in obese people with cardiometabolic diseases (e.g., after certain duration of obesity), type of bariatric surgery (RYGB vs. sleeve gastrectomy), and comparative studies of obesity pharmacotherapies and bariatric surgery are needed to clarify the optimal treatment pathways for this common and growing disease.”

Clinical Topics: Prevention, Hypertension

Keywords: Antihypertensive Agents, Gastric Bypass, Diabetes Mellitus, Type 2, Blood Pressure, Polypharmacy, Bariatric Surgery, Weight Loss, Hypertension, Gastrectomy

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