A study published in the journal Circulation has for the first time shown that intensive lifestyle modification involving exercise, weight loss and DASH (Dietary Approaches to Stop Hypertension) diet with sodium restriction resulted in significant decline in clinic and ambulatory BP.¹

The objective of the TRIUMPH (Treating Resistant Hypertension Using Lifestyle Modification to Promote Health) trial was to compare the impact of supervised intensive lifestyle modification against standard advice in achieving clinically significant decrease in BP in patients with resistant hypertension. For this the researchers enrolled 140 patients with resistant hypertension between June 2015 and October 2019 and randomized them to either a Center-Based Lifestyle Intervention (C-LIFE) or Standardized Education and Physician Advice (SEPA) with 2:1 allocation for a period of 4 months. Their mean age was 63 years; 31% of the participants were diabetic, while 21% had chronic kidney disease (CKD). Forty-eight percent were female and nearly 69% were Black. Patients with secondary hypertension, moderate-severe ischemic heart disease, major psychiatric disorder or substance dependence, including alcohol, diabetes requiring insulin and estimated glomerular filtration rate <40 mL/min/1.73 m² were excluded from the trial.

The C-LIFE group was educated about the DASH diet by a nutritionist in addition to weekly 45-minute group counseling sessions and supervised exercise at a cardiac rehabilitation facility 3 times per week for 30-45 minutes. The SEPA group received a one-hour educational session on BP management plus a workbook with instructions regarding individualized diet and exercise program.

Participants in the C-LIFE group achieved greater reduction in clinic systolic BP to the tune of >12mmHg compared to 7 mmHg in the SEPA group. After 4 months, nearly 60% of C-LIFE group were able to attain the goal of clinic BP <130/80 mm Hg. Similarly, participants in the C-LIFE group also showed a significant decrease in 24-hour ambulatory systolic BP of 7 mm Hg, whereas the ambulatory BP remained unchanged in the SEPA group (-0.3 mm Hg). Participants in both groups lost weight, but the weight loss in the C-LIFE group was considerable (nearly 7kg) compared to the SEPA group (nearly 4 kg).

Significant improvement in the physiological cardiovascular disease risk markers was noted in the C-LIFE group versus the SEPA group; resting baroreflex sensitivity (2.3 ms/mm Hg vs -1.1 ms/mm Hg), high-frequency heart rate variability (0.4 ln ms2 vs -0.2 ln ms2) and flow-mediated dilation (0.3% vs -1.4%). However, the pulse wave velocity and LV mass were comparable in the two groups.

Hypertension is a major risk factor for coronary heart disease, stroke, CKD, arrhythmias, and heart failure. It is a lifestyle disease, which means that adopting a healthy lifestyle can prevent and control hypertension.

The single-center TRIUMPH trial has shown that an intensive diet and exercise plan in a cardiac rehabilitation setting led to significant improvement in BP control in patients with resistant hypertension. According to the authors, prior to this trial, the effects of lifestyle modification have not been studied in patients with resistant hypertension and theirs is the first study to establish the benefits of “a structured and supervised program of lifestyle modifications” in reducing BP and also improving cardiovascular risk profile in this specific patient group.

The usual indications for cardiac rehabilitation include recent MI, acute coronary artery syndrome, chronic stable angina, CHF, post-CABG/PCI, valvular surgery and cardiac transplantation. Resistant hypertension can be added to this list as a new indication, suggest the authors, based on the results of the TRIUMPH trial.

Today is World Hypertension Day and the theme this year is “Measure your blood pressure accurately, control it, live longer”. Hence, accurate measurement of BP with the correct measurement technique is essential and the white-coat effect and medication nonadherence “pseudoresistance” must be excluded before making a diagnosis of resistant hypertension.

Reference

1. Blumenthal JA, et al. Effects of lifestyle modification on patients with resistant hypertension: results of the TRIUMPH randomized clinical trial. Circulation. 2021 Oct 12;144(15):1212-1226. doi: 10.1161/CIRCULATIONAHA.121.055329.