Treating Resistant Hypertension Using Lifestyle Modification to Promote Health - TRIUMPH

Contribution To Literature:

The TRIUMPH trial showed that intensive lifestyle modification compared with regular care reduces clinic and ambulatory BP among patients with resistant HTN and a baseline requirement of five antihypertensive agents.


The goal of the trial was to assess the effect of intensive lifestyle modification compared with regular care on blood pressure (BP) among patients with resistant hypertension (HTN).

Study Design

Eligible patients were randomized in a cluster randomized fashion to either C-LIFE (center-based lifestyle intervention, n = 90) or SEPA (standardized education and physician advice, n = 50) for 4 months.

The prescribed lifestyle changes were essentially the same for participants in both treatment arms, with the difference being the intensity of the delivery of the interventions.

  • Total screened: 266
  • Total number of enrollees: 140
  • Duration of follow-up: 4 months
  • Mean patient age: 63.0 years
  • Percentage female: 48%
  • Race: White 36%, Black 59%, Asian 1%

Inclusion criteria:

  • Patients with resistant HTN, defined as treatment for ≥6 weeks with ≥3 antihypertensive medications of different classes, including a diuretic, with clinic systolic BP (SBP) ≥130 mm Hg or diastolic BP (DBP) ≥80 mm Hg (modified from 140/90 mm Hg in November 2017), or the need for ≥4 drugs to achieve SBP ≤130 mm Hg and DBP ≤80 mm Hg, with SBP ≥120 mm Hg
  • Body mass index (BMI) ≥25 kg/m2
  • Lack of regular moderate or vigorous physical activity
  • Age 35-80 years

Exclusion criteria:

  • Known secondary hypertension
  • Estimated glomerular filtration rate <40 ml/min/1.73 m2
  • Moderate–severe ischemic heart disease
  • Diabetes requiring insulin
  • Major psychiatric disorder or substance dependence, including alcohol consumption >14 drinks/week

Other salient features/characteristics:

  • Baseline BP: 139/79 mm Hg
  • Weight: 230 lbs, BMI 36 kg/m2
  • Baseline LDL cholesterol: 99 mg/dl
  • Glucose: 110 mg/dl
  • Total antihypertensive agents at baseline: 5

Principal Findings:

The primary outcome of clinic SBP at 4 months, for C-LIFE vs. SEPA, was 126.8 mm Hg vs. 132.8 mm Hg (p = 0.005).

Secondary outcomes for C-LIFE vs. SEPA:

  • Clinic DBP: 73.2 mm Hg vs. 75.6 mm Hg (p = 0.034)
  • 24-hour ambulatory SBP/DBP: 126.4/67.2 vs. 133.2/70.8 mm Hg (p < 0.01 for both)
  • Improvement in baroreflex sensitivity: 2.3 vs. -1.1 ms/mm Hg (p = 0.003)
  • Resting high-frequency heart rate variability: 0.4 vs. -0.2 ln ms2 (p = 0.025)
  • Improvement in peak VO2: 14.8% vs. 3.4% (p = 0.0002)


The results of this trial indicate that intensive lifestyle modification compared with regular care reduces clinic and ambulatory BP among patients with resistant HTN (baseline requirement of five antihypertensive agents). This involved exercise, weight loss, and DASH (Dietary Approaches to Stop Hypertension) diet with sodium restriction. Improvements were also noted in various physiological parameters, but not in cardiometabolic risk markers per se. This is a small single-center but well-done and provocative trial. Since it involved multiple components, it is unclear if one particular intervention had more impact than others, or whether they had a synergistic effect. The long-term sustainability and benefit of this intervention will also need to be explored further.


Blumenthal JA, Hinderliter AL, Smith PJ, et al. Effects of Lifestyle Modification on Patients With Resistant Hypertension: Results of the TRIUMPH Randomized Clinical Trial. Circulation 2021;144:1212-26.

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Prevention, Diet, Exercise, Hypertension

Keywords: Antihypertensive Agents, Blood Pressure, Blood Pressure Monitoring, Ambulatory, Body Mass Index, Cardiac Rehabilitation, Cardiometabolic Risk Factors, Diet, Dietary Approaches To Stop Hypertension, Diuretics, Exercise, Heart Rate, Hypertension, Life Style, Metabolic Syndrome, Pharmaceutical Preparations, Primary Prevention, Vascular Diseases, Weight Loss

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