Disclosures: The authors report no relevant financial disclosures.
September 27, 2021
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Structured lifestyle program for resistant hypertension improves BP, multiple biomarkers

Disclosures: The authors report no relevant financial disclosures.
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A 4-month cardiac rehab program for treatment-resistant hypertension focused on diet, exercise and weight loss conferred greater improvement in both in-office and 24-hour ambulatory BP compared with a single educational session.

According to results from the TRIUMPH trial published in Circulation, the 4-month center-based lifestyle intervention also improved biomarkers for CVD including resting baroreflex sensitivity, high-frequency heart rate variability and flow-mediated dilation.

blood pressure cuff
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“It is surprising that lifestyle modification has not been rigorously evaluated in patients with resistant hypertension (RH),” James A. Blumenthal, PhD, professor in psychiatry and behavioral sciences, J. P. Gibbons Distinguished Professor of Psychiatry I and assistant professor in medicine at Duke University Medical Center, and colleagues wrote.

James A. Blumenthal

“Although estimates vary, RH is believed to affect 5% of the general population and 20% to 30% of hypertensive adults, with even higher rates among adults with risk factors for CVD such as diabetes or chronic kidney disease,” the researchers wrote. “RH is a particularly important designation because it is associated with a higher prevalence of end-organ damage and a 50% greater risk for adverse CVD events, including stroke, myocardial infarction and death, compared with controlled BP. Therefore, identifying effective treatments for lowering BP in patients with RH is timely and important.”

To address this issue, researchers conducted the TRIUMPH randomized clinical trial that evaluated a 4-month center-based lifestyle intervention of dietary counseling, behavioral weight management and exercise compared with a single educational session that provided the same lifestyle information plus written guidelines regarding specific exercise, weight loss and nutritional goals.

Researchers enrolled 140 patients (mean age, 63 years; 48% women; 59% Black; 31% with diabetes; 21% with chronic kidney disease) who were randomly assigned to the 4-month center-based intervention or a single counseling session as adjuvant therapy for treatment-resistant hypertension.

Results of TRIUMPH

The primary endpoint was clinic systolic BP. Secondary endpoints were 24-hour ambulatory BP and CVD biomarkers including baroreflex sensitivity, high-frequency heart rate variability, flow-mediated dilation, pulse wave velocity and left ventricular mass.

Blumenthal and colleagues observed that reductions of in-clinic systolic BP were greater among participants in the 4-month center-based lifestyle intervention (–12.5 mm Hg; 95% CI, –14.9 to –10.2) compared with those assigned to the single counseling session (–7.1 mm Hg; 95% CI, 10.4 to –3.7; P = .005). Patients’ 24-hour ambulatory systolic BP was reduced in the 4-month center-based lifestyle intervention (–7 mm Hg; 95% CI, –8.5 to –4) but not in the single counseling session (–0.3 mm Hg; 95% CI, –4 to 3.4; P = .001).

According to the study, the 4-month center-based intervention was also associated with greater improvements in resting baroreflex sensitivity (2.3 vs. –1.1 ms/mm Hg; P < .001), high-frequency heart rate variability (0.4 vs. –0.2 ln ms2; P < .001) and flow-mediated dilation (0.3% vs. –1.4%; P = .022) compared with a single counseling session. Researchers reported no significant differences for the outcomes of pulse wave velocity (P = .958) or LV mass (P = .596).

“Our findings showed lifestyle modifications among people with resistant hypertension can help them successfully lose weight and increase their physical activity, and as a result, lower blood pressure and potentially reduce their risk of heart attack or stroke,” Blumenthal said in a press release. “While some people can make lifestyle changes on their own, a structured program of supervised exercise and dietary modifications conducted by a multidisciplinary team of health care professionals in cardiac rehabilitation programs is likely more effective.”

A replicable model

“Though we usually think about recommending lifestyle changes like losing weight and getting more physical activity before starting medications, this study provides important reinforcement that adding lifestyle changes in conjunction with medications — and when medications alone are not doing the job — is an effective strategy,” Bethany Barone Gibbs, PhD, FAHA, associate professor in the department of health and human development and clinical and translational sciences at the University of Pittsburgh and AHA volunteer expert, said in the release. “Also exciting is that Blumenthal et al used a cardiac rehab model, which can be duplicated in many settings.”

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