Overweight and obesity treatment in the management of hypertension

Konstantinos Tsioufis, MD, is a professor of cardiology at the University of Athens, Greece, and director of the hypertension unit of the First Cardiology Clinic in the Hippokration Hospital. He has served as president of the European Society of Hypertension (ESH).

What is the role of overweight and obesity treatment in the current management of hypertension?

Konstantinos Tsioufis, MD: First of all, I would like to say that obesity and hypertension very often coexist. In the majority of cases an obese hypertensive patient also suffers from diabetes mellitus. It is important when we treat an obese hypertensive patient, first of all, to have as priority to achieve the blood pressure (BP) targets, which are the same as in the general population: <140 mm Hg for systolic BP and <90 mm Hg for diastolic BP.

But when we treat hypertension in an obese subject, we have to take into account not only to achieve the BP targets but also not to deteriorate the obesity status and not to deteriorate the metabolic status, which is unfavorable in the majority of cases. Our first priority is to recommend reducing the extra kilos. We know that this is not an easy task, but it is very beneficial. If you just keep in mind that in one study, in a variance [analysis], [when] patients even at the level of high normal BP reduced [their weight by] ~3 kilos, the incidence of hypertension was 20% compared to 90% in those without having this loss of weight.

On the other hand, there is no difference to the medication that we administer in obese hypertensive patients compared to those not obese, but you have to avoid diuretics or beta-blockers, particularly, to avoid deterioration of metabolic effects of these drugs. We also have new medications like sodium-glucose cotransporter-2 (SGLT-2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists, which also have some beneficial effect in the reduction of BP. But the main benefits of these drugs are associated with reduced hospitalization for heart failure and better cardiovascular outcome. It must be kept in mind that those patients with obesity and hypertension with associated heart failure with preserved ejection fraction (HFpEF) should receive this medication.

Last but not least, bariatric surgery may have a role in treating hypertension in an obese subject, but up to now we don’t have evidence that bariatric surgery has a pure net effect, beneficial effect on the BP levels. But, of course, bariatric surgery has an indication to improve the metabolic profile and also to improve the quality of life of these patients.