Metabolic Surgery for Hypertension in Patients With Obesity

Factors Associated with Statin Discontinuation Following Metabolic and Bariatric Surgery: A Retrospective Analysis of 2012-2021 Electronic Medical Records Network Data

BACKGROUND

Bariatric surgery has been shown to improve hyperlipidemia, decreasing the need for statin medications. Although maintaining statin therapy post-surgery for those with a history of atherosclerotic cardiovascular disease (ASCVD) is advised, it is uncertain if discontinuation risks differ between those with and without ASCVD history.

AIM

The study aims to analyze the rate and reasons for statin cessation post-bariatric surgery in the US using real-world data.

METHODS

Using the TriNetX electronic medical records network from 2012 to 2021, the study involved patients aged 18 or older on statins at the time of bariatric surgery. They were categorized into primary and secondary prevention groups based on prior ASCVD. Statin discontinuation was defined as a 90-day gap post the last statin dosage. The Cox model assessed factors influencing statin cessation.

RESULTS

Seven hundred and thirty-three statin users undergoing bariatric surgery were identified, with 564 (77%) in primary prevention. Six months post-surgery, 48% of primary prevention patients and 34.5% of secondary ones stopped statins. Primary prevention patients had a 30% higher likelihood of cessation compared to secondary prevention (hazard ratio, 1.30; 95% CI, 1.06-1.60) as shown by multivariable analysis.

CONCLUSIONS

Post-bariatric surgery, primary prevention patients are more likely to discontinue statins than secondary prevention patients.

Metabolic surgery in improving arterial health in obese individuals

PURPOSE

Arterial stiffness has gained recognition as a stand-alone risk factor for cardiovascular disease (CVD). Obesity is intricately linked to elevated arterial stiffness, the development of left ventricular (LV) hypertrophy, and the emergence of diastolic dysfunction, all of which collectively contribute substantially to an unfavorable prognosis. Weight loss has become a standard recommendation for all patients with CVD concurrent with morbid obesity; however, randomized evidence to support this recommendation was limited earlier. The latest scientific studies revealed dynamic changes in aortic stiffness after substantial weight loss by bariatric surgery, also known as metabolic surgery, in patients with obesity. There is also a favorable evolution in LV hypertrophy and a significant impact on arterial hypertension and other promising cardiovascular outcomes in obese people after bariatric surgery.

METHODS/RESULTS

We aimed to examine the cardiovascular effects of various metabolic surgeries in morbidly obese individuals, especially their role in improving arterial health, the potential impact on surrogate markers of atherosclerotic vascular disease, and consequently reducing the likelihood of cardiovascular events.

CONCLUSION

In conclusion, metabolic surgery is associated with a significant decrease in the occurrence of major adverse cardiovascular events (MACE) and all-cause mortality among obese individuals, alongside remarkable enhancement of arterial health. These findings underscore the critical importance of implementing strategies to combat obesity and reduce adiposity within the general population.

Randomized Trial of Effect of Bariatric Surgery on Blood Pressure After 5 Years

BACKGROUND

Obesity represents a major obstacle for controlling hypertension, the leading risk factor for cardiovascular mortality.

OBJECTIVES

The purpose of this study was to determine the long-term effects of bariatric surgery on hypertension control and remission.

METHODS

We conducted a randomized clinical trial with subjects with obesity grade 1 or 2 plus hypertension using at least 2 medications. We excluded subjects with previous cardiovascular events and poorly controlled type 2 diabetes. Subjects were assigned to Roux-en-Y gastric bypass (RYGB) combined with medical therapy (MT) or MT alone. We reassessed the original primary outcome (reduction of at least 30% of the total antihypertensive medications while maintaining blood pressure levels <140/90 mm Hg) at 5 years. The main analysis followed the intention-to-treat principle.

RESULTS

A total of 100 subjects were included (76% women, age 43.8 ± 9.2 years, body mass index: 36.9 ± 2.7 kg/m2). At 5 years, body mass index was 36.40 kg/m2 (95% CI: 35.28-37.52 kg/m2) for MT and 28.01 kg/m2 (95% CI: 26.95-29.08 kg/m2) for RYGB (P < 0.001). Compared with MT, RYGB promoted a significantly higher rate of number of medications reduction (80.7% vs 13.7%; relative risk: 5.91; 95% CI: 2.58-13.52; P < 0.001) and the mean number of antihypertensive medications was 2.97 (95% CI: 2.33-3.60) for MT and 0.80 (95% CI: 0.51-1.09) for RYGB (P < 0.001). The rates of hypertension remission were 2.4% vs 46.9% (relative risk: 19.66; 95% CI: 2.74-141.09; P < 0.001). Sensitivity analysis considering only completed cases revealed consistent results. Interestingly, the rate of apparent resistant hypertension was lower after RYGB (0% vs 15.2%).

CONCLUSIONS

Bariatric surgery represents an effective and durable strategy to control hypertension and related polypharmacy in subjects with obesity. (GAstric bypass to Treat obEse Patients With steAdy hYpertension [GATEWAY]; NCT01784848).

Management of Resistant Hypertension

Resistant hypertension (RH) is a severe form of hypertension associated with increased cardiovascular risk. Although true RH affects less than 10% of the patients receiving antihypertensive therapy, the absolute number is high and continues to increase. The workup of these patients requires screening for secondary hypertension and pseudoresistance, including poor adherence to prescribed medicines and the white-coat phenomenon. The treatment of RH consists of lifestyle modifications and pharmacological therapies. Lifestyle modifications include dietary adjustments, weight loss, physical activity, and limiting alcohol consumption; pharmacological therapies include diuretics, mineralocorticoid receptor antagonists, beta blockers, angiotensin receptor-neprilysin inhibitors, and others. Over the last 15 years, interventional approaches have emerged as adjunct treatment options; we highlight catheter-based renal denervation. This review summarizes the rationales and latest clinical evidence and, based thereon, proposes an updated algorithm for the management of RH.

Is prior bariatric surgery associated with poor COVID-19 outcomes? A systematic review and meta-analysis of case-control studies

Background

Obesity is an independent risk factor for severe coronavirus disease 2019 (COVID-19), but there is little evidence on whether prior bariatric surgery benefits the outcomes of patients with COVID-19. We aimed to summarize this relationship by conducting a systematic review and meta-analysis of current case-control studies.

Methods

We searched several electronic databases for case-control studies conducted between January 2020 and March 2022. We compared the rates of mortality, mechanical ventilation, intensive care unit (ICU) admission, dialysis, hospitalization, and length of hospital stay between COVID-19 patients with and without a history of bariatric surgery.

Results

We included six studies with 137 903 patients; 5270 (3.8%) had prior bariatric surgery, while 132 633 (96.2%) did not. COVID-19 patients with a history of bariatric surgery had significantly lower mortality (odds ratio (OR) = 0.42; 95% confidence interval (CI) = 0.23-0.74), ICU admission (OR = 0.48; 95% CI = 0.36-0.65), and mechanical ventilation rates than those with a history of non-bariatric surgery (OR = 0.51; 95% CI = 0.35-0.75).

Conclusions

Prior bariatric surgery was associated with a reduced risk of mortality and reduced severity of COVID-19 in patients with obesity compared to those with no prior bariatric surgery. Further large-sample prospective studies are needed to support these results.

Registration

CRD42022323745.

Major adverse cardiovascular events among patients with type-2 diabetes, a nationwide cohort study comparing primary metabolic and bariatric surgery to GLP-1 receptor agonist treatment

BACKGROUND

Glucagon-like Peptide-1 receptor agonists (GLP-1 RA) and metabolic and bariatric surgery (MBS) both improve cardiovascular outcomes in patients with severe obesity and type-2 diabetes (T2D). The aim of the present study was to assess the impact of MBS on major cardiovascular adverse events (MACE) in patients with severe obesity and T2D compared to patients with T2D treated with GLP-1 RA.

SUBJECTS AND METHODS

In this propensity score matched cohort study on nationwide data, patients with T2D and severe obesity who underwent MBS in Sweden from 2007 until 2019 were identified from the Scandinavian Obesity Surgery Registry and matched to a non-surgical group with T2D treated with GLP-1 RA (81.7% liraglutide, 9.0% dulaglutide, 6.0% exenatide, 1.6% lixisenatide and 0.8% semaglutide) from the general population using generalized linear model. Major outcome was MACE (hospitalization for acute coronary syndrome or cerebrovascular event or all-cause death), evaluated with multivariable Cox regression.

RESULTS

In total 2161 patients (obesity class I (10.2%), class II (40.3%), class III (49.5%)) were matched to 2161 non-surgical patients (mean age 51.1 ± 9.29 vs 51.5 ± 8.92 years, 64.8% vs. 64.4% women, with mean number of diabetes drugs of 2.5 ± 0.89 vs 2.6 ± 0.87, a mean duration of diabetes of 6.0 ± 4.15 vs 6.0 ± 4.51 years with 44.2% vs. 42.8% being treated with insulin at baseline). During the study period, 113 patients (8-year cumulative incidence 9.3%) compared to 130 non-surgical patients (8-year cumulative incidence 11.3%) suffered from MACE or all-cause mortality (HR 0.76, 95%CI 0.59-0.98), and 69 patients (8-year cumulative incidence 5.1%) compared to 92 non-surgical patients (8-year cumulative incidence 7.6%) suffered from a non-fatal MACE (HR 0.68, 95%CI 0.49-0.93).

CONCLUSION

In this matched cohort study, MBS was associated with lower risk for MACE compared to treatment with early GLP-1 RA in patients with T2D.

The Multiple Etiologies of Abdominal Pain Post Roux-en-Y Gastric Bypass: A Case Series and Review of Management Strategies

Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric surgeries performed and has aided many people with their weight loss efforts. However, manipulating the gastrointestinal anatomy may have numerous consequences. Various complications of RYGB can occur during the early to late post-op periods, and abdominal pain is the most common symptom reported. The etiologies that present as abdominal pain are heterogeneous in anatomical origin, onset, severity, and management; therefore, differentiating diagnoses is crucial. The physical exam, inciting triggers, and alleviating factors can direct diagnostic measures accordingly. Prompt recognition and identification of these patients' underlying causes of abdominal pain are vital for accurate diagnosis and treatment. Methods can range from conservative management to surgical intervention, depending on the severity of the complication. In this report, we recount the cases of two patients who underwent elective RYGB and presented to the emergency department (ED) months later with abdominal pain. After the labs were taken and diagnostic tests were conducted, it was discovered that both patients had multiple underlying factors that could have contributed to their pain. This study aims to describe the diverse etiologies of abdominal pain encountered in these bariatric patients and explore the appropriate management strategies utilized for each case.

Hypertension management in patients with cardiovascular comorbidities

Arterial hypertension is a leading cause of death globally. Due to ageing, the rising incidence of obesity, and socioeconomic and environmental changes, its incidence increases worldwide. Hypertension commonly coexists with Type 2 diabetes, obesity, dyslipidaemia, sedentary lifestyle, and smoking leading to risk amplification. Blood pressure lowering by lifestyle modifications and antihypertensive drugs reduce cardiovascular (CV) morbidity and mortality. Guidelines recommend dual- and triple-combination therapies using renin–angiotensin system blockers, calcium channel blockers, and/or a diuretic. Comorbidities often complicate management. New drugs such as angiotensin receptor-neprilysin inhibitors, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and non-steroidal mineralocorticoid receptor antagonists improve CV and renal outcomes. Catheter-based renal denervation could offer an alternative treatment option in comorbid hypertension associated with increased sympathetic nerve activity. This review summarises the latest clinical evidence for managing hypertension with CV comorbidities.

Integrated Care Model of Adiposity-Related Chronic Diseases

PURPOSE OF REVIEW

Although obesity is a disease, most patients with obesity do not undergo effective treatment nor adhere to long-term care. We examine the barriers that patients with obesity confront when searching for effective treatment and propose an integrated care model of adiposity-related chronic diseases in a cardio-renal metabolic unit.

RECENT FINDINGS

The current care of obesity is fragmented between primary care providers, medical specialists and metabolic bariatric surgeons with little or no coordination of care between these providers. The current care of obesity heavily focuses on weight loss as the primary aim of treatment thereby reenforcing the weight stigma and turning patients away from effective therapy like metabolic bariatric surgery. An interdisciplinary cardio-renal metabolic unit that, besides weight loss, emphasizes prevention/remission of adiposity-related chronic diseases may deliver thorough and rewarding care to most patients with obesity.

Cardiovascular Disease Risk Reduction and Body Mass Index

PURPOSE OF REVIEW

Anti-hypertensive and lipid lowering therapy addresses only half of the cardiovascular disease risk in patients with body mass index > 30 kg/m², i.e., obesity. We examine newer aspects of obesity pathobiology that underlie the partial effectiveness of anti-hypertensive lipid lowering therapy for the reduction of cardiovascular disease risk in obesity.

RECENT FINDINGS

Obesity-related insulin resistance, vascular endothelium dysfunction, increased sympathetic nervous system/renin-angiotensin-aldosterone system activity, and glomerulopathy lead to type 2 diabetes, coronary atherosclerosis, and chronic disease kidney disease that besides hypertension and dyslipidemia increase cardiovascular disease risk. Obesity increases cardiovascular disease risk through multiple pathways. Optimal reduction of cardiovascular disease risk in patients with obesity is likely to require therapy targeted at both obesity and obesity-associated conditions.

Methodological appraisal of the evidence about efficacy of metabolic surgery in adults with non-morbid obesity and hypertension: An overview of systematic reviews

BACKGROUND

Nowadays, the high morbimortality of obesity is mainly related to diabetes, cancer, and hypertension. It is reported that obesity in patients with hypertension can lead to resistance to pressure reduction through pharmacological therapy and lifestyle changes, so bariatric surgery emerges as a proposed treatment for obesity.

METHODS

We performed an umbrella review that included systematic reviews of clinical trials that evaluated patients with hypertension and non-morbid obesity. The quality and certainty of the evidence was evaluated with the AMSTAR-II and GRADE tools.

RESULTS

677 systematic reviews were identified, of which only three were included for analysis. We considered the outcomes addressed by the reviews on hypertension, identifying that 5 RCTs evaluated pressure reduction at 1 year of follow-up and 5 RCTs at more than 1 year, 5 RCTs evaluated hypertension rate, 6 RCTs analyzed changes in systolic pressure and 5 RCTs changes in diastolic pressure. Likewise, when assessing the methodological quality, it was concluded that the three reviews have critically low quality.

CONCLUSIONS

We found only three systematic reviews that evaluated the topic with critically low methodological quality. They reported results in favor of metabolic surgery, but with very low certainty of evidence.

Remission and Relapse of Hypertension After Bariatric Surgery: A Retrospective Study on Long-Term Outcomes

To compare hypertension remission and relapse after bariatric surgery compared with usual care.

Background

The effect of Roux-en-Y gastric bypass and sleeve gastrectomy on hypertension remission and relapse has not been studied in large, multicenter studies over long periods and using clinical blood pressure (BP) measurements.

Methods

This retrospective cohort study was set in Kaiser Permanente Washington, Northern California, and Southern California. Participants included 9432 patients with hypertension 21-65 years old who underwent bariatric surgery during 2005-2015 and 66,651 nonsurgical controls matched on an index date on study site, age, sex, race/ethnicity, body mass index, comorbidity burden, diabetes status, diastolic and systolic BP, and number of antihypertensive medications.

Results

At 5 years, the unadjusted cumulative incidence of hypertension remission was 60% (95% confidence interval [CI], 58-61%) among surgery patients and 14% (95% CI, 13-14%) among controls. At 1 year, the adjusted hazard ratio for the association of bariatric surgery with hypertension remission was 10.24 (95% CI, 9.61-10.90). At 5 years, the adjusted hazard ratio was 2.10 (95% CI, 1.57-2.80). Among those who remitted, the unadjusted cumulative incidence of relapse at 5 years after remission was 54% (95% CI, 51-56%) among surgery patients and 78% (95% CI 76-79%) among controls, although the adjusted hazard ratio was not significant (hazard ratio, 0.71; 95% CI, 0.46-1.08).

Conclusions

Bariatric surgery was associated with greater hypertension remission than usual care suggesting that bariatric surgery should be discussed with patients with severe obesity and hypertension. Surgical patients who experience remission should be monitored carefully for hypertension relapse.

Effects of bariatric surgery on cardiorespiratory fitness: A systematic review and meta-analysis

Although bariatric surgery (BS) is recognized as an effective strategy for body weight loss, its impact on cardiorespiratory fitness (CRF) is still unclear. We aimed to examine postoperative changes in CRF (VO_2max/peak ) and its relationship with weight loss among adults undergoing BS. We systematically searched the WoS, PubMed, MEDLINE, and Scopus databases. Observational and intervention studies were selected reporting the presurgery and postsurgery CRF, measured by breath-by-breath VO₂ or its estimation. Eleven articles (312 patients) revealed that BS leads to a reduction in absolute VO_2max/peak in the short term (effect size, ES = -0.539; 95%CI = -0.708, -0.369; p < 0.001), and those patients who suffered a more significant decrease in BMI after BS also had a greater loss of absolute VO_2max/peak . However, VO_2max/peak relative to body weight increased after surgery (ES = 0.658; 95%CI = 0.473, 0.842; p < 0.001). An insufficient number of studies were found investigating medium and long-term changes in CRF after BS. This study provides moderate-quality evidence that the weight loss induced by BS can reduce CRF in the short term, which represents a therapeutic target to optimize BS outcomes. More high-quality studies are needed to evaluate the impact of BS on VO_2max/peak in the short, medium, and long term including normalized values for fat-free mass.

Changes in Antihypertensive Medication Following Bariatric Surgery

Obesity is a leading cause of hypertension (i.e., high blood pressure [BP]). While hypertension can be managed with antihypertensive medication, substantial weight loss can also lower BP, reducing the need for antihypertensive medication. Articles in this review (n = 60) presented data on antihypertensive medication use among adults pre- and postoperatively. Roux-en-Y gastric bypass was the most studied surgical approach followed by Laparoscopic Sleeve Gastrectomy. Antihypertensive medication was discontinued in a large proportion of patients after surgery, and the mean number of antihypertensive medications decreased by approximately one. In almost a third of the studies, over 75% of participants experienced hypertension remission. All articles aside from two reported a decrease in systolic BP, with about 40% reporting a decrease of ≥ 10 mm Hg.

Is Hypertension Despite Use of Two or More Anti-hypertensive Medications for Patients with a BMI < 40 kg/m2 Justified for Eligibility for Bariatric Surgery?

PURPOSE

Several insurance policies require the presence of hypertension, defined as blood pressure > 140 mmHg systolic (SBP), or 90 mmHg diastolic (DBP), despite concurrent use of >1 anti-hypertensive agents for patients with a BMI <40 kg/m² to qualify for bariatric surgery (BS). The scientific validity of this requirement is assessed.

MATERIAL AND METHODS

A total of 461 patients who underwent BS in a community hospital were included. Systolic (SBP) and diastolic (DBP) blood pressure BP (in mmHg) was assessed by an automated manometer at each office visit until 3 years postoperatively and recorded in a prospectively maintained database.

RESULTS

Thirty-six (7.8%) patients with BMI <40 Kg/m², treated by 1, 2, or three anti-hypertensive medications and BP below 140/90, would have been denied BS under such policies. Number of anti-hypertensive medications had no impact on SBP/DBP control preoperatively. Patients being treated preoperatively with < 3 anti-hypertensive medications had a significantly higher percentage of hypertension resolution at 1 (one-med: 66.2%, two-med: 50.9% vs. three-med: 12.5%, p<.0001), 2 (one-med: 63.9%, two-med: 52.8% vs. three-med: 15.4%, p=.0068), and 3 (one-med: 76.9%, two-med: 52.9% vs. three-med: 20%, p=.005) years postoperatively. Multivariate regression demonstrated a significant correlation between the number of preoperative anti-hypertensive medications, preoperative SBP or DBP, and %TBWL.

CONCLUSION

Patients treated with fewer than 3 anti-hypertensive medications did not have a better BP control preoperatively but were more likely to resolve their hypertension postoperatively. Restricting access to BS of patients with hypertension treated by fewer than 3 anti-hypertensive medications is not supported by this study.

Insulin resistance, metabolic syndrome, and blood pressure progression among Blacks: the Jackson Heart Study

OBJECTIVE

There is a paucity of data on the relations of insulin resistance with incident blood pressure (BP) changes among Blacks. We investigated the associations of insulin resistance and metabolic syndrome (MetS) with BP progression in a community-based sample of African Americans.

METHODS

We analyzed 1064 participants without hypertension at baseline (2000-2004) who attended at least one follow-up visit in 2005-2008 or 2009-2013. Four insulin resistance indices [fasting insulin, insulin-to-glucose ratio (IGR), homeostasis model assessment of insulin resistance (HOMA-IR), and quantitative insulin sensitivity check index (QUICKI)] and MetS (excluding hypertension in the definition) were assessed at baseline. Robust Poisson regression was used to generate risk ratios (RRs) and 95% confidence intervals (CI) for BP progression and incident hypertension.

RESULTS

Over a median of 7 years, 69.6% progressed to a higher BP category and 62.7% developed hypertension. After multivariable adjustment, participants in the highest quartile of HOMA-IR had higher risks of BP progression [RR 1.25 (95% CI 1.09-1.43), Ptrend = 0.004] and hypertension [RR 1.35 (95% CI 1.16-1.58), Ptrend < 0.001] compared with those in the lowest quartile. A similar positive association of insulin resistance with BP outcomes was noted with insulin resistance assessed using IGR, fasting insulin, and QUICKI. MetS was associated with increased risks of BP progression [RR 1.15 (95% CI 1.02-1.30), P = 0.02] and incident hypertension [RR 1.23 [95% CI 1.08-1.41], P = 0.002]. These associations were present across baseline BP categories.

CONCLUSION

Our findings support the notion that higher insulin resistance levels are associated with greater risks of BP progression and incident hypertension among Blacks.

Short-term changes in the serum metabolome after laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass

INTRODUCTION

Bariatric surgery is known to be the most effective treatment for weight loss in obese patients and for the rapid remission of obesity-related comorbidities. These short-term improvements result from not only limited digestion or absorption but also dynamic changes in metabolism throughout the whole body. However, short-term metabolism studies associated with bariatric surgery in Asian individuals have not been reported.

OBJECTIVES

The aim of this study was to investigate the short-term metabolome changes in the serum promoted by laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) and to determine the underlying mechanisms that affect obesity-related comorbidities.

METHODS

Serum samples were collected from Korean patients who underwent RYGB or SG before and 4 weeks after the surgery. Metabolomic and lipidomic profiling was performed using UPLC-Orbitrap-MS, and data were analyzed using statistical analysis.

RESULTS

Metabolites mainly related to amino acids, lipids (fatty acids, glycerophospholipids, sphingolipids, glycerolipids) and bile acids changed after surgery, and these changes were associated with the lowering of risk factors for obesity-related diseases such as nonalcoholic fatty liver disease (NAFLD), type 2 diabetes (T2D) and atherosclerosis. Interestingly, the number of significantly altered metabolites related to the lipid metabolism were greater in SG than in RYGB. Furthermore, the metabolites related to amino acid metabolism were significantly changed only after SG, whereas bile acid changed significantly only following RYGB.

CONCLUSION

These differences could result from anatomical differences between the two surgeries and could be related to the gut microbiota. This study provides crucial information to expand the knowledge of the common but different molecular mechanisms involved in obesity and obesity-related comorbidities affected by each bariatric procedure.

Non-interventional weight changes affect systolic blood pressure in normotensive individuals

The association between obesity and hypertension is well established. Weight loss has been shown to reduce blood pressure (BP) among hypertensive patients. Nevertheless, the effect of weight changes on BP in normotensive individuals is less clear. The author explored the association between non‐interventional weight alterations and BP changes in a large cohort of normotensive adults. This is a retrospective analysis of normotensive individuals, between 2010 and 2018. All weight changes were non‐interventional. Body mass index (BMI) and BP were measured annually. Patients were divided according to the change in BMI between visits: reduction of more than 5% ("large reduction"), between 2.5% and 5% ("moderate reduction"), reduction of <2.5% or elevation of <2.5% ("unchanged"), elevation between 2.5% and 5% ("moderate increase"), and elevation of more than 5% ("large increase"). The primary outcome was the change in systolic BP (SBP) between the visits. The final analysis included 8723 individuals. 20% of the patients reduced their BMI by at least 2.5% and 24.5% increased their BMI by more than 2.5%. "High reduction" inferred an absolute decrease of 3.6 mmHg in SBP, while "large increase" resulted in an absolute increase of 1.9 mmHg in SBP. The proportion of individuals with at least 10 mmHg decrease in SBP progressively declined according to the relative decrease in BMI, and the proportion of patients with at least 10 mmHg increase in SBP progressively increased. This effect was more pronounced in individuals with higher baseline SBP. Among normotensive adults, modest non‐interventional weight changes may have significant effects on SBP.

Metabolic effects of bariatric surgery on patients with type 2 diabetes: a population-based study

BACKGROUND

Bariatric surgery among patients with obesity and type 2 diabetes (T2D) can induce complete remission. However, it remains unclear whether sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) has better T2D remission within a population-based daily practice.

OBJECTIVES

To compare patients undergoing RYGB and SG on the extent of T2D remission at the 1-year follow-up.

SETTING

Nationwide, population-based study including all 18 hospitals in the Netherlands providing metabolic and bariatric surgery.

METHODS

Patients undergoing RYGB and SG between October 2015 and October 2018 with 1 year of complete follow-up data were selected from the mandatory nationwide Dutch Audit for Treatment of Obesity (DATO). The primary outcome is T2D remission within 1 year. Secondary outcomes include ≥20% total weight loss (TWL), obesity-related co-morbidity reduction, and postoperative complications with a Clavien-Dindo (CD) grade ≥III within 30 days. We compared T2D remission between RYGB and SG groups using propensity score matching to adjust for confounding by indication.

RESULTS

A total of 5015 patients were identified from the DATO, and 4132 (82.4%) had completed a 1-year follow-up visit. There were 3350 (66.8%) patients with a valid T2D status who were included in the analysis (RYGB = 2623; SG = 727). RYGB patients had a lower body mass index than SG patients, but were more often female, with higher gastroesophageal reflux disease and dyslipidemia rates. After adjusting for these confounders, RYGB patients had increased odds of achieving T2D remission (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.14-2.1; P < .01). Groups were balanced after matching 695 patients in each group. After matching, RYGB patients still had better odds of T2D remission (OR, 1.91; 95% CI, 1.27-2.88; P < .01). Also, significantly more RYGB patients had ≥20%TWL (OR, 2.71; 95% CI, 1.96-3.75; P < .01) and RYGB patients had higher dyslipidemia remission rates (OR, 1.96; 95% CI, 1.39-2.76; P < .01). There were no significant differences in CD ≥III complications.

CONCLUSION

Using population-based data from the Netherlands, this study shows that RYGB leads to better T2D remission rates at the 1-year follow-up and better metabolic outcomes for patients with obesity and T2D undergoing bariatric surgery in daily practice.

Characteristics and resolution of hypertension in obese African American bariatric cohort

Weight reduction continues to be first-line therapy in the treatment of hypertension (HTN). However, the long-term effect of bariatric malabsorptive surgical techniques such as Roux-en-Y Gastric Bypass (RYGB) surgery in the management of hypertension (HTN) is less clear. African Americans (AA) are disproportionately affected by obesity and hypertension and have inconsistent outcomes after bariatric surgery (BS). Despite a plethora of bariatric literature, data about characteristics of a predominantly AA bariatric hypertensive cohort including hypertension in obese (HIO) are scarce and underreported. The aims of this study were, (1) to describe the preoperative clinical characteristics of HIO with respect to HTN status and age, and (2) to identify predictors of HTN resolution one year after RYGB surgery in an AA bariatric cohort enrolled at the Howard University Center for Wellness and Weight Loss Surgery (HUCWWS). In the review of 169 AA bariatric patients, the average BMI was 48.50 kg/m² and the average age was 43.86 years. Obese hypertensive patients were older (46 years vs. 37.89 years; p < .0001); had higher prevalence of diabetes mellitus (DM, 43.09% vs. 10.87%; p < .0001) and dyslipidemia (38.2% vs. 13.04%; p 0.002). Hypertensive AA who were taking ≥ 2 antihypertensive medications prior to RYGB were 18 times less likely to experience HTN resolution compared to hypertensive AA taking 0–1 medications, who showed full or partial response. Also, HIO was less likely to resolve after RYGB surgery in patients who needed ≥ 2 antihypertensive medications prior to surgical intervention.

Roux-en-Y gastric bypass and sleeve gastrectomy for obesity-associated hypertension

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) reduce blood pressure (BP) in obese patients with hypertension (HTN). We compared the effect of RYGB and SG on BP in obese patients with HTN at a large-volume, private bariatric surgery center using a propensity score analysis. The measurement and management of BP were exclusively left to the patient's provider without any involvement of Tulane investigators. At month 1, RYGB and SG equally decreased: (1) mean body weight: 12.7 vs 13.2 kg (p=not significant (NS)) (2) systolic/diastolic BP: 8.5/5.3 vs 8.0/4.2 mm Hg (p=NS) and (3) average number of antihypertensive medications from 1.5 to 0.8 and from 1.6 to 0.6 per patient (p=NS). From month 1 to 12, BP remained unchanged after RYGB but tended to increase from month 6 to 12 after SG. Remission of HTN occurred in 52% and 44% of patients after RYGB and SG. In contrast to the full effect of RYGB and SG on BP at 1 month, body weight decreases steadily over 12 months after RYGB and SG. In conclusion, early after surgery, RYGB and SG equally reduce BP in obese patients with HTN. Thereafter, RYGB has a more sustained effect on BP than SG.

Three-Year Outcomes of Bariatric Surgery in Patients With Obesity and Hypertension : A Randomized Clinical Trial

BACKGROUND

Midterm effects of bariatric surgery on patients with obesity and hypertension remain uncertain.

OBJECTIVE

To determine the 3-year effects of Roux-en-Y gastric bypass (RYGB) on blood pressure (BP) compared with medical therapy (MT) alone.

DESIGN

Randomized clinical trial. (ClinicalTrials.gov: NCT01784848).

SETTING

Investigator-initiated study at Heart Hospital (HCor), São Paulo, Brazil.

PARTICIPANTS

Patients with hypertension receiving at least 2 medications at maximum doses or more than 2 medications at moderate doses and with a body mass index (BMI) between 30.0 and 39.9 kg/m² were randomly assigned (1:1 ratio).

INTERVENTION

RYGB plus MT or MT alone.

MEASUREMENTS

The primary outcome was at least a 30% reduction in total number of antihypertensive medications while maintaining BP less than 140/90 mm Hg. Key secondary outcomes were number of antihypertensive medications, hypertension remission, and BP control according to current guidelines (<130/80 mm Hg).

RESULTS

Among 100 patients (76% female; mean BMI, 36.9 kg/m² [SD, 2.7]), 88% from the RYGB group and 80% from the MT group completed follow-up. At 3 years, the primary outcome occurred in 73% of patients from the RYGB group compared with 11% of patients from the MT group (relative risk, 6.52 [95% CI, 2.50 to 17.03]; P < 0.001). Of the randomly assigned participants, 35% and 31% from the RYGB group and 2% and 0% from the MT group achieved BP less than 140/90 mm Hg and less than 130/80 mm Hg without medications, respectively. Median (interquartile range) number of medications in the RYGB and MT groups at 3 years was 1 (0 to 2) and 3 (2.8 to 4), respectively (P < 0.001). Total weight loss was 27.8% and -0.1% in the RYGB and MT groups, respectively. In the RYGB group, 13 patients developed hypovitaminosis B₁₂ and 2 patients required reoperation.

LIMITATION

Single-center, nonblinded trial.

CONCLUSION

RYGB is an effective strategy for midterm BP control and hypertension remission, with fewer medications required in patients with hypertension and obesity.

PRIMARY FUNDING SOURCE

Ethicon, represented in Brazil by Johnson & Johnson do Brasil.

Association of Metabolic Surgery With Major Adverse Cardiovascular Outcomes in Patients With Previous Myocardial Infarction and Severe Obesity: A Nationwide Cohort Study

BACKGROUND

The number of patients with myocardial infarction and severe obesity is increasing and there is a lack of evidence how these patients should be treated. The aim of this study was to investigate the association between metabolic surgery (Roux-en-Y gastric bypass and sleeve gastrectomy) and major adverse cardiovascular events in patients with previous myocardial infarction (MI) and severe obesity.

METHODS

Of 566 patients with previous MI registered in the SWEDEHEART registry (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) undergoing metabolic surgery and registered in the nationwide Scandinavian Obesity Surgery Registry, 509 patients (Roux-en-Y gastric bypass n=465; sleeve gastrectomy n=44) could be matched 1:1 to a control with MI from SWEDEHEART, but no subsequent metabolic surgery regarding sex, age (±3 years), year of MI (±3 years), and body mass index (±3). The 2 groups were well matched, except for a lower proportion of reduced ejection fraction after MI (7% versus 12%), previous heart failure (10% versus 19%), atrial fibrillation (6% versus 10%), and chronic obstructive pulmonary disease (4% versus 7%) in patients undergoing metabolic surgery.

RESULTS

The median (interquartile range) follow-up time was 4.6 (2.7-7.1) years. The 8-year cumulative probability of major adverse cardiovascular events was lower in patients undergoing metabolic surgery (18.7% [95% CI, 15.9-21.5%] versus 36.2% [33.2-39.3%], adjusted hazard ratio, 0.44 [95% CI, 0.32-0.61]). Patients undergoing metabolic surgery had also a lower risk of death (adjusted HR, 0.45 [95% CI, 0.29-0.70]; MI, 0.24 [0.14-0.41]) and new onset heart failure, but there were no significant differences regarding stroke (0.91 [0.38-2.20]) and new onset atrial fibrillation (0.56 [0.31-1.01]).

CONCLUSIONS

In severely obese patients with previous MI, metabolic surgery is associated with a low risk for serious complications, lower risk of major adverse cardiovascular events, death, new MI, and new onset heart failure. These findings need to be confirmed in a randomized, controlled trial.

Benefits and Risks of Bariatric Surgery in Adults: A Review

Importance

Severe obesity and its related diseases, such as type 2 diabetes, hypertension, dyslipidemia, and sleep apnea, are very common in the United States, but currently very few patients with these conditions choose to undergo bariatric surgery. Summaries of the expanding evidence for both the benefits and risks of bariatric surgery are needed to better guide shared decision-making conversations.

Observations

There are approximately 252 000 bariatric procedures (per 2018 numbers) performed each year in the US, of which an estimated 15% are revisions. The 1991 National Institutes of Health guidelines recommended consideration of bariatric surgery in patients with a body mass index (calculated as weight in kilograms divided by height in meters squared) of 40 or higher or 35 or higher with serious obesity-related comorbidities. These guidelines are still widely used; however, there is increasing evidence that bariatric procedures should also be considered for patients with type 2 diabetes and a body mass index of 30 to 35 if hyperglycemia is inadequately controlled despite optimal medical treatment for type 2 diabetes. Substantial evidence indicates that surgery results in greater improvements in weight loss and type 2 diabetes outcomes, compared with nonsurgical interventions, regardless of the type of procedures used. The 2 most common procedures used currently, the sleeve gastrectomy and gastric bypass, have similar effects on weight loss and diabetes outcomes and similar safety through at least 5-year follow-up. However, emerging evidence suggests that the sleeve procedure is associated with fewer reoperations, and the bypass procedure may lead to more durable weight loss and glycemic control. Although safety is a concern, current data indicate that the perioperative mortality rates range from 0.03% to 0.2%, which has substantially improved since early 2000s. More long-term randomized studies are needed to assess the effect of bariatric procedures on cardiovascular disease, cancer, and other health outcomes and to evaluate emerging newer procedures.

Conclusions and Relevance

Modern bariatric procedures have strong evidence of efficacy and safety. All patients with severe obesity-and especially those with type 2 diabetes-should be engaged in a shared decision-making conversation about the risks and benefits of surgery compared with continuing usual medical and lifestyle treatment, and the decision about surgery should be driven primarily by informed patient preferences.

Onco-Metabolic Surgery: A Combined Approach to Gastric Cancer and Hypertension

Purpose

The purpose of this study was to explore the changes in blood pressure in patients with concurrent gastric cancer and hypertension after gastrectomy, and to identify the factors that affect the changes in blood pressure.

Materials and Methods

Patients with concurrent gastric cancer and hypertension who underwent gastrectomy were retrospectively analyzed from January 2013 to December 2018. The pre- and 6-month postoperative medical records were compared. Predictors for the remission of hypertension were analyzed.

Results

A total of 143 patients with concurrent gastric cancer and hypertension were included in this study. The number of patients with complete remission, partial remission and no remission were 67 (46.9%), 12 (8.4%) and 64 (44.7%), respectively. The average of weight and BMI (body mass index) before gastrectomy were 63.0 ± 9.7 kg and 23.4 ± 2.9 kg/m², respectively, which were significantly higher than those 6-month postgastrectomy: 54.8 ± 9.8 kg and 20.4 ± 3.1 kg/m², respectively (p<0.001). The average number of antihypertensive medications before gastrectomy was 1.5 ± 0.6, while it was 0.8 ± 0.8 6-month postgastrectomy (p<0.001). Age (p<0.05) and the surgical techniques used (p<0.05) were significantly different between partial remission and no remission patients. Furthermore, age (p<0.05) and the surgical techniques used (p<0.05) were significantly different between complete remission and no remission patients. Age (p<0.05, odds ratio =0.933, 95% CI=0.890–0.978) and the surgical techniques used (p<0.05, odds ratio =2.749, 95% CI=1.132–6.677) are predictors for remission of hypertension.

Conclusion

Total gastrectomy is an onco-metabolic surgery that can cure younger patients with concurrent gastric cancer and hypertension. Age and the surgical techniques used can predict the remission of hypertension 6 months after gastrectomy.

Prevalence and associated factors of hypertension among adults in Gadarif in eastern Sudan: a community-based study

Background

Hypertension is becoming an increasingly common health issue worldwide, especially in countries in Sub-Saharan Africa. Hypertension is the leading risk factor for premature death and disability worldwide, and it is the leading risk factor for mortality from cardiovascular diseases worldwide. The data on hypertension in Sudan that has been published is limited. We conducted this study to assess the prevalence of hypertension and its associated risk factors.

Methods

A multistage sampling survey was conducted in Gadarif, Eastern Sudan, from January to May 2018 to investigate the prevalence of hypertension and associated factors in adults in Eastern Sudan. The World Health Organization (WHO) three-level stepwise approach questionnaire was used to gather sociodemographic characteristics (age, sex, height, weight marital status, education level, smoking habit, alcohol consumption habit, and family history of hypertension). Hypertension was defined as the presence of an average blood pressure of ≥140/90 mmHg or the reported use of anti-hypertensive medications for high blood pressure.

Results

A total of 600 participants (mean age: 44.9 years) were enrolled in this study. Four hundred twenty-two (70.3%) participants were women, and 196 (32.7%) participants were obese. Of the 600 enrolled participants, 245 (40.8%) individuals had hypertension, 44 (7.3%) had been previously diagnosed with hypertension, and 201 (33.5%) were newly diagnosed with hypertension. A logistic regression analysis showed no significant associations across the education level, marital status, overweight and hypertension factors. However, an older age (adjusted OR = 3.20, 95% CI = 2.28–4.51, P < 0.001) and obesity (adjusted OR = 2.41, 95% CI = 1.57–3.69, P < 0.001) were associated with the presence of hypertension.

Conclusion

There is a high rate of hypertension in Eastern Sudan, especially among older and obese individuals. Preventive measures, such as dietary measures, should be implemented.