Changes in Central 24-h Ambulatory Blood Pressure and Hemodynamics 12 Months After Bariatric Surgery: the BARIHTA Study

Comparison of hypertension remission and relapse after sleeve gastrectomy and one-anastomosis gastric bypass: a prospective cohort study

This study aimed to assess the remission and relapse of hypertension (HTN) in hypertensive individuals who underwent sleeve gastrectomy (SG) and one-anastomosis gastric bypass (OAGB) and identify the predictors of HTN remission and relapse following bariatric surgery. A prospective cohort study with a follow-up of 3 years was conducted on severely obese patients between 2013 and 2018. Hypertension remission was defined as the normalization of blood pressure (BP) with the discontinuation of medical treatment, and HTN relapse was defined as the need for the onset of antihypertensive drugs or the occurrence of BP impairment. A total of 787 hypertensive patients were included in this study. The cumulative incidence of HTN remission and relapse were 83.9% (95% CI: 81.6-86.5) and 31.4% (95% CI: 25.6-38.2), respectively. Remission and relapse were not significantly different among the patients undergoing either surgery (SG or OAGB). A higher remission rate was linked to a younger age and the use of fewer antihypertensive medications pre-operation. However, failure to successfully lose weight during the first year postoperative and weight regain predicted a higher risk of HTN relapse after 3 years. Following bariatric surgery, BP drops initially but then gradually rises. These alterations are responsible for about 31% relapse after 3 years in those who initially achieve remission. Patients who are younger and use less antihypertensive medications before surgery may benefit the most from bariatric surgery in terms of HTN. First-year successful weight loss and control of weight regain may prevent HTN relapse in the following years.

Exploring Renal Changes after Bariatric Surgery in Patients with Severe Obesity

Obesity-related hyperfiltration leads to an increased glomerular filtration rate (GFR) and hyperalbuminuria. These changes are reversible after bariatric surgery (BS). We aimed to explore obesity-related renal changes post-BS and to seek potential mechanisms. Sixty-two individuals with severe obesity were prospectively examined before and 3, 6 and 12 months post-BS. Anthropometric and laboratory data, 24 h-blood pressure, renin-angiotensin-aldosterone system (RAS) components, adipokines and inflammatory markers were determined. Both estimated GFR (eGFR) and albuminuria decreased from the baseline at all follow-up times (p-for-trend <0.001 for both). There was a median (IQR) of 30.5% (26.2–34.4) reduction in body weight. Plasma glucose, glycosylated hemoglobin, fasting insulin and HOMA-index decreased at 3, 6 and 12 months of follow-up (p-for-trend <0.001 for all). The plasma aldosterone concentration (median (IQR)) also decreased at 12 months (from 87.8 ng/dL (56.8; 154) to 65.4 (56.8; 84.6), p = 0.003). Both leptin and hs-CRP decreased (p < 0.001) and adiponectine levels increased at 12 months post-BS (p = 0.017). Linear mixed-models showed that body weight (coef. 0.62, 95% CI: 0.32 to 0.93, p < 0.001) and plasma aldosterone (coef. −0.07, 95% CI: −0.13 to −0.02, p = 0.005) were the independent variables for changes in eGFR. Conversely, glycosylated hemoglobin was the only independent variable for changes in albuminuria (coef. 0.24, 95% CI: 0.06 to 0.42, p = 0.009). In conclusion, body weight and aldosterone are the main factors that mediate eGFR changes in obesity and BS, while albuminuria is associated with glucose homeostasis.

Impact of Bariatric Surgery on Pulse Wave Velocity as a Measure of Arterial Stiffness: a Systematic Review and Meta-analysis

PURPOSE

Weight loss during post-bariatric surgery period has been linked to both reduced ASCVD mortality and overall mortality. Atherosclerosis causes arteries to lose their elasticity and become more stiff resulting in increased pulse wave velocity (PWV). It has been revealed that PWV favorably predicts subsequent ASCVDs. The goal of this systematic review and meta-analysis was to see how bariatric surgery affected PWV, an index of arterial stiffness.

MATERIALS AND METHODS

A systematic literature search in four databases was performed. Also, Cochrane guidelines were reviewed to determine bias possibility in the related studies. Comprehensive Meta-Analysis (CMA) V2 software is used to conduct the meta-analysis. Studies were evaluated regarding heterogeneity in design, populations under investigation, and treatment duration using random-effects model and the generic inverse variance weighting approach. A random-effect meta-regression approach was used to investigate the association with the estimated effect size. Evaluation of funnel plot, Egger's weighted regression, and Begg's rank correlation tests were utilized to estimate the presence of publication bias in the meta-analysis.

RESULTS

The results of meta-analysis on 13 trials including 1426 individuals demonstrated a remarkable decline of PWV after bariatric surgery (WMD: -0.652, 95% CI: -1.004, -0.301, p<0.001). The random-effects meta-regression revealed no evidence of significant correlation between the changes in PWV and initial BMI, BMI changes, or duration of follow-up.

CONCLUSION

The decrease of PWV might be utilized as an independent surrogate marker of improvement of ASCVD risk after bariatric surgery.

Improvement of Arterial Stiffness One Month after Bariatric Surgery and Potential Mechanisms

Arterial stiffness (AS) is an independent predictor of cardiovascular risk. We aimed to analyze changes (Δ) in AS 1-month post-bariatric surgery (BS) and search for possible pathophysiological mechanisms. Patients with severe obesity (43% hypertensives) were prospectively evaluated before and 1-month post-BS, with AS assessed by pulse-wave velocity (PWV), augmentation index (AIx@75) and pulse pressure (PP). Ambulatory 24 h blood pressure (BP), anthropometric data, renin-angiotensin-aldosterone system (RAAS) components and several adipokines and inflammatory markers were also analyzed. Overall reduction in body weight was mean (interquartile range (IQR)) = 11.0% (9.6–13.1). A decrease in PWV, AIx@75 and PP was observed 1-month post-BS (all, p < 0.01). There were also significant Δ in BP, RAAS components, adipokines and inflammatory biomarkers. Multiple linear regression adjusted models showed that Δaldosterone was an independent variable (B coeff.95%CI) for final PWV (B = −0.003, −0.005 to 0.000; p = 0.022). Angiotensin-converting enzyme (ACE)/ACE2 and ACE were independent variables for final AIx@75 (B = 0.036, 0.005 to 0.066; p = 0.024) and PP (B = 0.010, 0.003 to 0.017; p = 0.01), respectively. There was no correlation between ΔAS and anthropometric changes nor with Δ of adipokines or inflammatory markers except high-sensitivity C-reactive protein (hs-CRP). Patients with PWV below median decreased PWV (mean, 95%CI = −0.18, −0.25 to −0.10; p < 0.001) and both AIx@75 and PP at 1-month, but not those with PWV above median. In conclusion, there is an improvement in AS 1-month post-BS that correlates with ΔBP and Δrenin-angiotensin-aldosterone components. The benefit is reduced in those with higher PWV.

Effect of bariatric surgery on cardiac structure and function in obese patients: Role of the renin-angiotensin system

Echocardiographic alterations have been described in obesity, but their modifications after bariatric surgery (BS) and mechanisms are little known, mostly in normotensive patients. We aimed to analyze cardiac changes 1 year post‐BS and to explore possible mechanisms. A cohort of patients with severe obesity (58% normotensives) were prospectively recruited and examined before surgery and after 12 months. Clinical and echocardiographic data, 24 h BP, renin‐angiotensin‐aldosterone system (RAAS) components, cytokines, and inflammatory markers were analyzed at these two time points. Overall reduction in body weight was mean (IQR) = 30.0% (25.9–33.8). There were statistically significant decreases in left ventricle mass index^2.7(LVMI)^2.7, septum thickness (ST), posterior wall thickness (PWT), relative wall thickness (RWT), and E/e’, both in the whole cohort and in patients without RAAS blockers (p ≤ .04 for all). Plasma renin activity (PRA) decreased from (median, IQR) = 0.8 (0.3;1.35) to 0.4 (0.2;0.93) ng/ml/h, plasma aldosterone from 92 (58.6;126) to 68.1 (56.2;83.4) ng/dl, and angiotensin‐converting enzyme (ACE)‐2 activity from 7.7 (5.7;11.8) to 6.8 (5.3;11.2) RFU/µl/h, p < .05. The body weight loss correlated with a decrease in both 24 h SBP and 24 h DBP (Pearson's coefficient 0.353, p = .022 and 0.384, p = .012, respectively). Variation (Δ) of body weight correlated with ΔE/e’ (Pearson's coeff. 0.414, p = .008) and with Δ lateral e’ (Pearson's coeff. = −0.363, p = .018). Generalized linear models showed that ΔPRA was an independent variable for the final (12‐months post‐BS) LVMI^2.7 (p = .028). No other changes in cardiac parameters correlated with ΔBP. In addition to the respective baseline value, final values of PWT and RWT were dependent on 12‐month Δ of PRA, ACE, and ACE/ACE2 (p < .03 for all). We conclude that there are cardiac changes post‐BS in patients with severe obesity, normotensives included. Structural changes appear to be related to modifications in the renin‐angiotensin axis.