Diet plus exercise keeps BP in check for patients with resistant hypertension

A structured lifestyle modification programme that combines a healthy eating plan and regular aerobic exercise promotes blood pressure (BP) control and improves cardiovascular disease biomarkers in patients with resistant hypertension, as shown in the TRIUMPH study.

Compared with a single session of Standardized Education and Physician Advice (SEPA), the lifestyle intervention yielded a greater reduction in clinic systolic BP (–12.5 mm Hg, 95 percent confidence interval [CI], –14.9 to –10.2 vs –7.1 mm Hg, 95 percent CI, –10.4 to –3.7; p=0.005), as well as in the 24-hour ambulatory systolic BP (–7.0 mm Hg, 95 percent CI, –8.5 to –4.0 vs –0.3 mm Hg, 95 percent CI, –4.0 to 3.4; p=0.001). [Circulation 2021;doi:10.1161/CIRCULATIONAHA.121.055329]

“[T]he present findings provide strong support for the value of providing an intensive, structured intervention to achieve these benefits. Although patients with resistant hypertension who received a 1-hour counselling session that included educational materials and advice for optimal BP management achieved significant clinic SBP reductions, no change was observed in ambulatory BP,” according to the investigators.

The lifestyle intervention was an intensive 4-month programme that involved the adoption of the Dietary Approaches to Stop Hypertension (DASH) diet with caloric and salt restriction (≤2,300 mg/d) and engagement in a 30–45-min session of aerobic exercise (70–85 percent initial heart rate reserve) three times a week (Center-Based Lifestyle Intervention [C-LIFE]), delivered in a cardiac rehabilitation setting.

Of the 140 patients (mean age 63 years, 48 percent female, 59 percent Black, 31 percent with diabetes, 21 percent with chronic kidney disease) who were randomized in TRIUMPH, 90 underwent C-LIFE and 50 received SEPA. On average, they were prescribed 3.5 antihypertensive medications.

Accordingly, patients in the C-LIFE group showed greater improvements in aerobic fitness and functional capacity, as measured by peak VO2, compared with those in the SEPA group (14.8 percent vs 3.4 percent; p=0.002). Moreover, the C-LIFE group achieved substantial weight loss (–15.3 vs –8.5 lbs; p<0.001) and a larger reduction in urinary sodium excretion (–308 vs –187 mg/d; p=0.007).

Changes in other outcomes were also more favourable in the C-LIFE group vs the SEPA group, including resting baroreflex sensitivity (2.3 vs –1.1 ms/mm Hg; p<0.001), high-frequency heart rate variability (0.4 vs –0.2 ln ms2; p<0.001), and flow-mediated dilation (0.3 percent vs –1.4 percent; p=0.022). There were no between-group differences in pulse wave velocity (p=0.958) and left ventricular mass (p=0.596).

“The combination of exercise, weight loss, and the DASH diet with sodium restriction is not only effective for unmedicated hypertensive patients, as had been demonstrated previously, but also produces clinically significant BP-lowering benefits in patients with resistant hypertension,” the investigators noted. [Arch Intern Med 2010;170:126-135]

“The BP reductions in TRIUMPH are comparable with those observed with antihypertensive medications and were achieved without contributing to pill burden and the risk of medication interactions and untoward side effects,” they added. [Hypertension 2008;51:1403-1419]

TRIUMPH, although not without limitations, indicates that successful lifestyle changes can best be achieved by a comprehensive, multidisciplinary team of health professionals within the established cardiac rehabilitation setting, the investigators pointed out.

“[P]olicymakers should consider resistant hypertension as a new indication for cardiac rehabilitation with appropriate coverage by governmental agencies and private insurers,” they said.