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Schiavon CA, Cavalcanti AB, Oliveira JD, Machado RHV, Santucci EV, Santos RN, Oliveira JS, Damiani LP, Junqueira D, Halpern H, Monteiro FDLJ, Noujaim PM, Cohen RV, de Sousa MG, Bortolotto LA, Berwanger O, Drager LF. Randomized Trial of Effect of Bariatric Surgery on Blood Pressure After 5 Years. J Am Coll Cardiol 2024; 83:637-648. [PMID: 38325988 DOI: 10.1016/j.jacc.2023.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/23/2023] [Accepted: 11/08/2023] [Indexed: 02/09/2024]
Abstract
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).
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Affiliation(s)
- Carlos A Schiavon
- Research Institute, Heart Hospital (hcor), São Paulo, Brazil; Hospital BP, A Beneficencia Portuguesa de São Paulo, São Paulo, Brazil.
| | | | - Juliana D Oliveira
- Research Institute, Heart Hospital (hcor), São Paulo, Brazil; Hospital BP, A Beneficencia Portuguesa de São Paulo, São Paulo, Brazil
| | | | | | - Renato N Santos
- Research Institute, Heart Hospital (hcor), São Paulo, Brazil
| | | | - Lucas P Damiani
- Research Institute, Heart Hospital (hcor), São Paulo, Brazil
| | | | - Helio Halpern
- Surgical Center, Heart Hospital (hcor), São Paulo, Brazil
| | | | | | | | - Marcio G de Sousa
- Dante Pazzanese Institute of Cardiology, Department of Hypertension, São Paulo, Brazil
| | - Luiz A Bortolotto
- Unidade de Hipertensão, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Otavio Berwanger
- Imperial College London, George Institute for Global Health UK, London, United Kingdom
| | - Luciano F Drager
- Unidade de Hipertensão, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Unidade de Hipertensão, Disciplina de Nefrologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Hospital Sírio Libanes, São Paulo, Brazil
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Oliveira JD, Schiavon CA, Oliveira JS, Santos RN, Damiani LP, Ikeoka D, Santucci EV, Machado RHV, Bortolotto LA, Berwanger O, Cavalcanti AB, Drager LF. Shorter History of Hypertension as a Predictor of Hypertension Remission after 3-years of Bariatric Surgery: Data from the GATEWAY Trial. Obes Surg 2023; 33:2485-2492. [PMID: 37392354 DOI: 10.1007/s11695-023-06711-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Previous evidence explored predictors of hypertension (HTN) remission after bariatric but data are limited to observational studies and lack of ambulatory blood pressure monitoring (ABPM). This study was aimed to evaluate the rate of HTN remission after bariatric surgery using ABPM and to define predictors of mid-term HTN remission. METHODS We included patients enrolled in the surgical arm of the GATEWAY randomized trial. HTN remission was defined as controlled blood pressure (< 130 × 80 mmHg) evaluated by 24-h ABPM while no need of anti-hypertensive medications after 36 months. A multivariable logistic regression model was used to assess the predictors of HTN remission after 36 months. RESULTS 46 patients submitted Roux-en-Y gastric bypass (RYGB). HTN remission occurred in 39% (n = 14 out of 36 patients with complete data at 36 months). Patients with HTN remission had shorter HTN history than no remission group (5.9 ± 5.5 vs. 12.5 ± 8.1 years; p = 0.01). The baseline insulin levels were lower in patients who presented HTN remission, although not statistically significant (OR: 0.90; CI 95%: 0.80-0.99; p = 0.07). In the multivariate analysis, the HTN history (years) was the only independent predictor of HTN remission (OR: 0.85; 95% CI: 0.70-0.97; p = 0.04). Therefore, for each additional year of HTN history, the chance of HTN remission decreases by approximately 15% after RYGB. CONCLUSION After 3 years of RYGB, HTN remission defined by ABPM was common and independently associated with a shorter HTN history. These data underscore the need of early effective approach of obesity aiming greater impact in its comorbidities.
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Affiliation(s)
- Juliana D Oliveira
- Unidade de Hipertensão, Disciplina de Nefrologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Avenida Dr Eneas de Carvalho Aguiar, 255, São Paulo, CEP 05403-900, Brazil
- Research Institute - Heart Hospital (HCor) - São Paulo, São Paulo, Brazil
| | - Carlos A Schiavon
- Research Institute - Heart Hospital (HCor) - São Paulo, São Paulo, Brazil
- Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Julia S Oliveira
- Research Institute - Heart Hospital (HCor) - São Paulo, São Paulo, Brazil
| | - Renato N Santos
- Research Institute - Heart Hospital (HCor) - São Paulo, São Paulo, Brazil
| | | | - Dimas Ikeoka
- Research Institute - Heart Hospital (HCor) - São Paulo, São Paulo, Brazil
| | - Eliana V Santucci
- Research Institute - Heart Hospital (HCor) - São Paulo, São Paulo, Brazil
| | | | - Luiz A Bortolotto
- Unidade de Hipertensão, Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Luciano F Drager
- Unidade de Hipertensão, Disciplina de Nefrologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Avenida Dr Eneas de Carvalho Aguiar, 255, São Paulo, CEP 05403-900, Brazil.
- Unidade de Hipertensão, Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
- Cardiology Center, Hospital Sírio Libanês, São Paulo, Brazil.
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Maia IS, Kawano-Dourado L, Zampieri FG, Damiani LP, Nakagawa RH, Gurgel RM, Negrelli K, Gomes SP, Paisani D, Lima LM, Santucci EV, Valeis N, Laranjeira LN, Lewis R, Fitzgerald M, Carvalho CR, Brochard L, Cavalcanti AB. High flow nasal catheter therapy versus non-invasive positive pressure ventilation in acute respiratory failure (RENOVATE trial): protocol and statistical analysis plan. CRIT CARE RESUSC 2022; 24:61-70. [PMID: 38046839 PMCID: PMC10692619 DOI: 10.51893/2022.1.oa8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The best way to offer non-invasive respiratory support across several aetiologies of acute respiratory failure (ARF) is presently unclear. Both high flow nasal catheter (HFNC) therapy and non-invasive positive pressure ventilation (NIPPV) may improve outcomes in critically ill patients by avoiding the need for invasive mechanical ventilation (IMV). Objective: Describe the details of the protocol and statistical analysis plan designed to test whether HFNC therapy is non-inferior or even superior to NIPPV in patients with ARF due to different aetiologies. Methods: RENOVATE is a multicentre adaptive randomised controlled trial that is recruiting patients from adult emergency departments, wards and intensive care units (ICUs). It takes advantage of an adaptive Bayesian framework to assess the effectiveness of HFNC therapy versus NIPPV in four subgroups of ARF (hypoxaemic non-immunocompromised, hypoxaemic immunocompromised, chronic obstructive pulmonary disease exacerbations, and acute cardiogenic pulmonary oedema). The study will report the posterior probabilities of non-inferiority, superiority or futility for the comparison between HFNC therapy and NIPPV. The study assumes neutral priors and the final sample size is not fixed. The final sample size will be determined by a priori determined stopping rules for non-inferiority, superiority and futility for each subgroup or by reaching the maximum of 2000 patients. Outcomes: The primary endpoint is endotracheal intubation or death within 7 days. Secondary outcomes are 28-day and 90-day mortality, and ICU-free and IMV-free days in the first 28 days. Results and conclusions: RENOVATE is designed to provide evidence on whether HFNC therapy improves, compared with NIPPV, important patient-centred outcomes in different aetiologies of ARF. Here, we describe the rationale, design and status of the trial. Trial registration:ClinicalTrials.gov NCT03643939.
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Affiliation(s)
- Israel S. Maia
- HCor Research Institute, Hospital do Coracao, Sao Paulo, Brazil
- Anesthesiology Division, Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Leticia Kawano-Dourado
- HCor Research Institute, Hospital do Coracao, Sao Paulo, Brazil
- Pulmonary Division, Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | | | | | | | | | - Karina Negrelli
- HCor Research Institute, Hospital do Coracao, Sao Paulo, Brazil
| | | | - Denise Paisani
- HCor Research Institute, Hospital do Coracao, Sao Paulo, Brazil
| | - Lucas M. Lima
- HCor Research Institute, Hospital do Coracao, Sao Paulo, Brazil
| | | | - Nanci Valeis
- HCor Research Institute, Hospital do Coracao, Sao Paulo, Brazil
| | | | - Roger Lewis
- University of California, Los Angeles (UCLA), Los Angeles, California, USA
- Berry Consultants, Austin, Texas, USA
| | | | | | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Alexandre B. Cavalcanti
- HCor Research Institute, Hospital do Coracao, Sao Paulo, Brazil
- Anesthesiology Division, Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - For the RENOVATE Investigators and the BRICNet
- HCor Research Institute, Hospital do Coracao, Sao Paulo, Brazil
- Anesthesiology Division, Medical School, University of Sao Paulo, Sao Paulo, Brazil
- Pulmonary Division, Medical School, University of Sao Paulo, Sao Paulo, Brazil
- University of California, Los Angeles (UCLA), Los Angeles, California, USA
- Berry Consultants, Austin, Texas, USA
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
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Zampieri FG, Machado FR, Biondi RS, Freitas FGR, Veiga VC, Figueiredo RC, Lovato WJ, Amêndola CP, Assunção MSC, Serpa-Neto A, Paranhos JLR, Andrade J, Godoy MMG, Romano E, Dal Pizzol F, Silva EB, Silva MML, Machado MCV, Malbouisson LMS, Manoel ALO, Thompson MM, Figueiredo LM, Soares RM, Miranda TA, de Lima LM, Santucci EV, Corrêa TD, Azevedo LCP, Kellum JA, Damiani LP, Silva NB, Cavalcanti AB. Effect of Slower vs Faster Intravenous Fluid Bolus Rates on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA 2021; 326:830-838. [PMID: 34547081 PMCID: PMC8356145 DOI: 10.1001/jama.2021.11444] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Slower intravenous fluid infusion rates could reduce the formation of tissue edema and organ dysfunction in critically ill patients; however, there are no data to support different infusion rates during fluid challenges for important outcomes such as mortality. OBJECTIVE To determine the effect of a slower infusion rate vs control infusion rate on 90-day survival in patients in the intensive care unit (ICU). DESIGN, SETTING, AND PARTICIPANTS Unblinded randomized factorial clinical trial in 75 ICUs in Brazil, involving 11 052 patients requiring at least 1 fluid challenge and with 1 risk factor for worse outcomes were randomized from May 29, 2017, to March 2, 2020. Follow-up was concluded on October 29, 2020. Patients were randomized to 2 different infusion rates (reported in this article) and 2 different fluid types (balanced fluids or saline, reported separately). INTERVENTIONS Patients were randomized to receive fluid challenges at 2 different infusion rates; 5538 to the slower rate (333 mL/h) and 5514 to the control group (999 mL/h). Patients were also randomized to receive balanced solution or 0.9% saline using a factorial design. MAIN OUTCOMES AND MEASURES The primary end point was 90-day survival. RESULTS Of all randomized patients, 10 520 (95.2%) were analyzed (mean age, 61.1 years [SD, 17.0 years]; 44.2% were women) after excluding duplicates and consent withdrawals. Patients assigned to the slower rate received a mean of 1162 mL on the first day vs 1252 mL for the control group. By day 90, 1406 of 5276 patients (26.6%) in the slower rate group had died vs 1414 of 5244 (27.0%) in the control group (adjusted hazard ratio, 1.03; 95% CI, 0.96-1.11; P = .46). There was no significant interaction between fluid type and infusion rate (P = .98). CONCLUSIONS AND RELEVANCE Among patients in the intensive care unit requiring fluid challenges, infusing at a slower rate compared with a faster rate did not reduce 90-day mortality. These findings do not support the use of a slower infusion rate. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02875873.
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Affiliation(s)
- Fernando G Zampieri
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
| | - Flávia R Machado
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Department of Anesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Rodrigo S Biondi
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Instituto de Cardiologia do Distrito Federal, Brasília, Brazil
| | - Flávio G R Freitas
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Hospital SEPACO, São Paulo, Brazil
| | - Viviane C Veiga
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Rodrigo C Figueiredo
- Hospital Maternidade São José, Centro Universitário do Espírito Santo (UNESC), Colatina, Brazil
| | - Wilson J Lovato
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | | | | | - Ary Serpa-Neto
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jorge L R Paranhos
- Santa Casa de Misericórdia de São João Del Rei, São João Del Rei, Brazil
| | - José Andrade
- Hospital Geral de Vitória da Conquista, Vitória da Conquista, Brazil
| | - Michele M G Godoy
- Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, Brazil
| | | | - Felipe Dal Pizzol
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Hospital São José, Criciúma, Brazil
| | | | | | | | | | | | - Marlus M Thompson
- Hospital Evangélico Cachoeiro do Itapemirim, Cachoeiro do Itapemirim, Brazil
| | | | | | | | | | | | - Thiago D Corrêa
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Luciano C P Azevedo
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Hospital Sírio Libanês, São Paulo, Brazil
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Nilton B Silva
- School of Medicine, Federal University of Health Sciences, Porto Alegre, Brazil
| | - Alexandre B Cavalcanti
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
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Furlan SF, Drager LF, Santos RN, Damiani LP, Bersch-Ferreira AC, Miranda TA, Machado RHV, Santucci EV, Bortolotto LA, Lorenzi-Filho G, Berwanger O, Cavalcanti AB, Schiavon CA. Three-year effects of bariatric surgery on obstructive sleep apnea in patients with obesity grade 1 and 2: a sub-analysis of the GATEWAY trial. Int J Obes (Lond) 2021; 45:914-917. [PMID: 33589771 DOI: 10.1038/s41366-021-00752-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 12/21/2020] [Accepted: 01/12/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Most of the evidence on bariatric surgery on obstructive sleep apnea (OSA) is based on observational studies and/or short-term follow-up in patients with obesity grade 3. SUBJECTS/METHODS This randomized study compared the effects of roux-en-Y gastric bypass (RYGB) or usual care (UC) on OSA severity in patients with obesity grade 1-2. Mild, moderate, and severe OSA was defined by the apnea-hypopnoea index (AHI): 5-14.9; 15-29.9, and ≥30 events/h, respectively. OSA remission was defined by converting any form of OSA into normal AHI (<5 events/h). RESULTS After 3-year of follow-up, the body-mass index increased in the UC while decreased in the RYGB group: +1.7 (-1.9; 2.7) versus -10.6 (-12.7; -9.2) kg/m2, respectively. The AHI increased by 5 (-4.2; 12.7) in the UC group while reduced in the RYGB group to -13.2 (-22.7; -7) events/h. UC significantly increase the frequency of moderate OSA (from 15.4 to 46.2%). In contrast, RYGB had a huge impact on reaching no OSA status (from 4.2 to 70.8%) in parallel to a decrease of moderate (from 41.7 to 8.3%) and severe OSA (from 20.8 to 0%). CONCLUSIONS RYGB is an attractive strategy for mid-term OSA remission or decrease moderate-to-severe forms of OSA in patients with obesity grade 1-2.
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Affiliation(s)
- Sofia F Furlan
- Program in Cardiology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil.,Hypertension Unit, University of São Paulo Medical School, São Paulo, Brazil
| | - Luciano F Drager
- Hypertension Unit, University of São Paulo Medical School, São Paulo, Brazil. .,Renal Division, University of São Paulo Medical School, São Paulo, Brazil.
| | | | - Lucas P Damiani
- Research Institute, Heart Hospital (HCor), São Paulo, Brazil
| | | | | | | | | | - Luiz A Bortolotto
- Hypertension Unit, University of São Paulo Medical School, São Paulo, Brazil
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Schiavon CA, Bhatt DL, Ikeoka D, Santucci EV, Santos RN, Damiani LP, Oliveira JD, Machado RHV, Halpern H, Monteiro FLJ, Noujaim PM, Cohen RV, de Souza MG, Amodeo C, Bortolotto LA, Berwanger O, Cavalcanti AB, Drager LF. Three-Year Outcomes of Bariatric Surgery in Patients With Obesity and Hypertension : A Randomized Clinical Trial. Ann Intern Med 2020; 173:685-693. [PMID: 32805133 DOI: 10.7326/m19-3781] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Carlos A Schiavon
- HCor Research Institute, São Paulo, Brazil (C.A.S., E.V.S., R.N.S., L.P.D., J.D.O., R.H.M., A.B.C.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts (D.L.B.)
| | | | - Eliana V Santucci
- HCor Research Institute, São Paulo, Brazil (C.A.S., E.V.S., R.N.S., L.P.D., J.D.O., R.H.M., A.B.C.)
| | - Renato Nakagawa Santos
- HCor Research Institute, São Paulo, Brazil (C.A.S., E.V.S., R.N.S., L.P.D., J.D.O., R.H.M., A.B.C.)
| | - Lucas P Damiani
- HCor Research Institute, São Paulo, Brazil (C.A.S., E.V.S., R.N.S., L.P.D., J.D.O., R.H.M., A.B.C.)
| | - Juliana D Oliveira
- HCor Research Institute, São Paulo, Brazil (C.A.S., E.V.S., R.N.S., L.P.D., J.D.O., R.H.M., A.B.C.)
| | - Rachel Helena V Machado
- HCor Research Institute, São Paulo, Brazil (C.A.S., E.V.S., R.N.S., L.P.D., J.D.O., R.H.M., A.B.C.)
| | - Helio Halpern
- HCor Surgical Center, São Paulo, Brazil (H.H., F.L.M., P.M.N.)
| | | | | | | | | | - Celso Amodeo
- Federal University of São Paulo, São Paulo, Brazil (C.A.)
| | - Luiz A Bortolotto
- University of São Paulo Medical School, São Paulo, Brazil (L.A.B., L.F.D.)
| | | | - Alexandre B Cavalcanti
- HCor Research Institute, São Paulo, Brazil (C.A.S., E.V.S., R.N.S., L.P.D., J.D.O., R.H.M., A.B.C.)
| | - Luciano F Drager
- University of São Paulo Medical School, São Paulo, Brazil (L.A.B., L.F.D.)
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7
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Schiavon CA, Ikeoka D, Santucci EV, Santos RN, Damiani LP, Bueno PT, Oliveira JD, Torreglosa CR, Bersch-Ferreira AC, Miranda TA, Barros SD, Halpern H, Monteiro FLJ, Cohen RV, Noujaim PM, de Souza MG, Amodeo C, Bortolotto LA, Berwanger O, Cavalcanti AB, Drager LF. Effects of Bariatric Surgery Versus Medical Therapy on the 24-Hour Ambulatory Blood Pressure and the Prevalence of Resistant Hypertension. Hypertension 2019; 73:571-577. [DOI: 10.1161/hypertensionaha.118.12290] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Carlos A. Schiavon
- From the Research Institute (C.A.S., E.V.S., R.N.S., L.P.D., P.T.B., J.D.O., C.R.T., A.C.B.-F., T.A.M., A.B.C.), Heart Hospital (HCor), São Paulo, Brazil
| | - Dimas Ikeoka
- Intensive Unit (D.I.), Heart Hospital (HCor), São Paulo, Brazil
| | - Eliana V. Santucci
- From the Research Institute (C.A.S., E.V.S., R.N.S., L.P.D., P.T.B., J.D.O., C.R.T., A.C.B.-F., T.A.M., A.B.C.), Heart Hospital (HCor), São Paulo, Brazil
| | - Renato Nakagawa Santos
- From the Research Institute (C.A.S., E.V.S., R.N.S., L.P.D., P.T.B., J.D.O., C.R.T., A.C.B.-F., T.A.M., A.B.C.), Heart Hospital (HCor), São Paulo, Brazil
| | - Lucas P. Damiani
- From the Research Institute (C.A.S., E.V.S., R.N.S., L.P.D., P.T.B., J.D.O., C.R.T., A.C.B.-F., T.A.M., A.B.C.), Heart Hospital (HCor), São Paulo, Brazil
| | - Priscila Torres Bueno
- From the Research Institute (C.A.S., E.V.S., R.N.S., L.P.D., P.T.B., J.D.O., C.R.T., A.C.B.-F., T.A.M., A.B.C.), Heart Hospital (HCor), São Paulo, Brazil
| | - Juliana D. Oliveira
- From the Research Institute (C.A.S., E.V.S., R.N.S., L.P.D., P.T.B., J.D.O., C.R.T., A.C.B.-F., T.A.M., A.B.C.), Heart Hospital (HCor), São Paulo, Brazil
| | - Camila R. Torreglosa
- From the Research Institute (C.A.S., E.V.S., R.N.S., L.P.D., P.T.B., J.D.O., C.R.T., A.C.B.-F., T.A.M., A.B.C.), Heart Hospital (HCor), São Paulo, Brazil
| | - Angela Cristine Bersch-Ferreira
- From the Research Institute (C.A.S., E.V.S., R.N.S., L.P.D., P.T.B., J.D.O., C.R.T., A.C.B.-F., T.A.M., A.B.C.), Heart Hospital (HCor), São Paulo, Brazil
| | - Tamiris A. Miranda
- From the Research Institute (C.A.S., E.V.S., R.N.S., L.P.D., P.T.B., J.D.O., C.R.T., A.C.B.-F., T.A.M., A.B.C.), Heart Hospital (HCor), São Paulo, Brazil
| | - Silvana de Barros
- Hypertension Unit, Renal Division (S.d.B., L.F.D.), University of São Paulo Medical School, Brazil
| | - Helio Halpern
- Surgical Center (H.H., F.L.J.M., P.M.N.), Heart Hospital (HCor), São Paulo, Brazil
| | | | | | - Patricia M. Noujaim
- Surgical Center (H.H., F.L.J.M., P.M.N.), Heart Hospital (HCor), São Paulo, Brazil
| | - Marcio G. de Souza
- Department of Hypertension, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil (M.G.d.S., C.A.)
| | - Celso Amodeo
- Department of Hypertension, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil (M.G.d.S., C.A.)
| | - Luiz A. Bortolotto
- Hypertension Unit, Heart Institute (InCor) (L.A.B., L.F.D.), University of São Paulo Medical School, Brazil
| | | | - Alexandre B. Cavalcanti
- From the Research Institute (C.A.S., E.V.S., R.N.S., L.P.D., P.T.B., J.D.O., C.R.T., A.C.B.-F., T.A.M., A.B.C.), Heart Hospital (HCor), São Paulo, Brazil
| | - Luciano F. Drager
- Hypertension Unit, Renal Division (S.d.B., L.F.D.), University of São Paulo Medical School, Brazil
- Hypertension Unit, Heart Institute (InCor) (L.A.B., L.F.D.), University of São Paulo Medical School, Brazil
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Schiavon CA, Ikeoka D, Santos RN, Santucci EV, Miranda TA, Damiani LP, Oliveira JD, Torreglosa CR, Bueno PT, Bersch-Ferreira AC, Noujaim PM, Cohen RV, Halpern H, Monteiro FLJ, Sousa MG, Amodeo C, Bortolloto L, Berwanger O, Cavalcanti AB, Drager LF. Does the RYGB Common Limb Length influence Hypertension Remission, Weight Loss and Cardio-Metabolic Parameters? Data from the GATEWAY TRIAL. Surg Obes Relat Dis 2018. [DOI: 10.1016/j.soard.2018.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Schiavon CA, Ikeoka D, Santucci EV, Santos RN, Damiani LP, Oliveira JD, Torreglosa CR, Bersch-Ferreira AC, Miranda TA, Barros SD, Halpern H, Monteiro FL, Cohen RV, Noujaim PM, Souza MG, Amodeo C, Bortolloto L, Berwanger O, Cavalcanti AB, Drager LF. Abstract P374: 24-h Blood Pressure Profile, Non-dipping Status And Incidence Of Resistant Hypertension In Patients Randomized To Bariatric Surgery Versus Medical Therapy: The Gateway Randomized Trial. Hypertension 2018. [DOI: 10.1161/hyp.72.suppl_1.p374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Bariatric surgery represents an effective strategy for office blood pressure (BP) reduction in obese hypertensive patients. However, no previous study evaluated the impact of bariatric surgery on 24-h BP profile, non-dipping status and incidence of resistant hypertension (RH).
Methods:
This is a sub-analysis of a randomized clinical trial including hypertensive patients with grade 1 and 2 obesity, aged 18 to 65 years, using at least 2 drugs at optimal doses or >2 at moderate doses. Patients were randomly allocated to either Roux-en-Y Gastric Bypass (RYGB) with medical therapy (MT) or MT alone for 12 months. We analyzed the 24-h BP profile, non-dipping status (defined by <10% of systolic BP reduction during sleep as compared to the daytime period) and RH incidence.
Results:
A total of 100 patients were included (76% female, age 43.8±9.2 years, BMI 36.9±2.7 Kg/m
2
). The 24-h BP profile was similar at 12 months in both groups, but the RYGB group required less anti-hypertensive classes compared to the MT alone (Figure). The rate of non-dipping BP did not change significantly during the follow-up (RYGB: from 18/48 (37.5%) to 22/48 (45.8%); p=0.30; MT: from 16/33 (48.5%) to 15/33 (45.5%); p=0.80). In an exploratory analysis, the incidence of RH was similar at the baseline (RYGB 10% (5/50) and MT 16% (8/50); p=0.38). After 12 months, it changed significantly in the RYGB group: 0% (0/49) while remained stable in the MT group: 14.9% (7/47) (p<0.001).
Conclusions:
RYGB significantly reduced anti-hypertensive medications while promoting similar 24-h BP profile and non-dipping BP status compared to the MT alone. RYGB may be an attractive strategy to reduce RH incidence in obese patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Márcio G Souza
- Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - Celso Amodeo
- Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
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10
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Berwanger O, Guimarães HP, Laranjeira LN, Cavalcanti AB, Kodama AA, Zazula AD, Santucci EV, Victor E, Tenuta M, Carvalho V, Mira VL, Pieper KS, Weber B, Mota LH, Peterson ED, Lopes RD. Effect of a multifaceted intervention on use of evidence-based therapies in patients with acute coronary syndromes in Brazil: the BRIDGE-ACS randomized trial. JAMA 2012; 307:2041-9. [PMID: 22665103 DOI: 10.1001/jama.2012.413] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Studies have found that patients with acute coronary syndromes (ACS) often do not receive evidence-based therapies in community practice. This is particularly true in low- and middle-income countries. OBJECTIVE To evaluate whether a multifaceted quality improvement (QI) intervention can improve the use of evidence-based therapies and reduce the incidence of major cardiovascular events among patients with ACS in a middle-income country. DESIGN, SETTING, AND PARTICIPANTS The BRIDGE-ACS (Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes) trial, a cluster-randomized (concealed allocation) trial conducted among 34 clusters (public hospitals) in Brazil and enrolling a total of 1150 patients with ACS from March 15, 2011, through November 2, 2011, with follow-up through January 27, 2012. INTERVENTION Multifaceted QI intervention including educational materials for clinicians, reminders, algorithms, and case manager training, vs routine practice (control). MAIN OUTCOME MEASURES Primary end point was the percentage of eligible patients who received all evidence-based therapies (aspirin, clopidogrel, anticoagulants, and statins) during the first 24 hours in patients without contraindications. RESULTS Mean age of the patients enrolled was 62 (SD, 13) years; 68.6% were men, and 40% presented with ST-segment elevation myocardial infarction, 35.6% with non-ST-segment elevation myocardial infarction, and 23.6% with unstable angina. The randomized clusters included 79.5% teaching hospitals, all from major urban areas and 41.2% with 24-hour percutaneous coronary intervention capabilities. Among eligible patients (923/1150 [80.3%]), 67.9% in the intervention vs 49.5% in the control group received all eligible acute therapies (population average odds ratio [OR(PA)], 2.64 [95% CI, 1.28-5.45]). Similarly, among eligible patients (801/1150 [69.7%]), those in the intervention group were more likely to receive all eligible acute and discharge medications (50.9% vs 31.9%; OR(PA),, 2.49 [95% CI, 1.08-5.74]). Overall composite adherence scores were higher in the intervention clusters (89% vs 81.4%; mean difference, 8.6% [95% CI, 2.2%-15.0%]). In-hospital cardiovascular event rates were 5.5% in the intervention group vs 7.0% in the control group (OR(PA), 0.72 [95% CI, 0.36-1.43]); 30-day all-cause mortality was 7.0% vs 8.4% (ORPA, 0.79 [95% CI, 0.46-1.34]). CONCLUSION Among patients with ACS treated in Brazil, a multifaceted educational intervention resulted in significant improvement in the use of evidence-based therapies. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00958958.
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Affiliation(s)
- Otávio Berwanger
- Research Institute HCor--Hospital do Coração, São Paulo, Brazil.
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