Choice of Blood Pressure Medications Impacts Long-Term Heart Disease Risk in Patients With HIV

For patients with HIV who develop high blood pressure, new research suggests that the type of medication chosen for their initial treatment can have a significant influence on their risk of heart disease, stroke, and heart failure, according to researchers from the Perelman School of Medicine at the University of Pennsylvania.

People with HIV who are receiving antiretroviral therapy (ART) are more likely to develop hypertension and hypertension-related heart problems than people who do not have the virus, according to the researchers. They said their study is the first to examine how the choice of blood pressure medications influences the long-term risk of heart disease, stroke, and heart failure in this population.

“We suspected there could be differences in risk based on which medications providers select to treat hypertension among people with HIV due to potential interactions between blood pressure medications and some therapies used to treat the virus,” said senior author Jordana B. Cohen, MD, MSCE, in the press release. “Additionally, factors such as how the body handles salt, inflammation, and the accelerated aging of blood vessels may affect the risk of cardiac events in people with HIV differently than people who do not have HIV, which could be influenced by which blood pressure medication is used.”

The investigators reviewed records of 8041 veterans with HIV who developed high blood pressure between 2000 and 2018. Of those, 6516 had never been diagnosed with heart or blood vessel problems. At baseline, 5979 were on ART and 6582 were prescribed single antihypertensive medication therapy.

“We were surprised by the high rates of beta-blockers prescribed for first-line hypertension treatment since they are not recommended as first-line agents,” Cohen said in the press release. “We suspect this may be due to the fact that many people with HIV receive primary care from their infectious disease team, who do an amazing job at managing HIV but may not be focused on blood pressure treatment guidelines and contraindications."

In their findings, the investigators found that 13% of the veterans with HIV were prescribed beta-blockers as their initial hypertension treatment. In 24% of patients, Single-medication treatment was started with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACEi/ARBs), whereas 23% started treatment with thiazide or similar diuretics and 11% started with calcium channel blockers (CCBs).

During the mean 6.5 years of follow-up, 25% of the veterans experienced a cardiovascular event. Among those who had not been diagnosed with heart disease at the beginning of the study, the risk of developing heart disease, heart failure, or stroke for the first time was 90% higher among those taking beta-blockers compared to those who were taking ACEi/ARBs. This increased risk was present regardless of whether blood pressure was under control, although thiazide diuretics and CCBs did not increase risk, according to the study.

Among patients with HIV who did not have chronic kidney disease, the use of ACEi/ARBs was associated with a lower risk of developing heart failure compared to patients taking other medications who had an approximately 50% higher risk of heart failure.

“Patients with HIV need heightened attention to their elevated risk of heart disease,” Cohen said in the press release. “More dedicated research studying the unique needs for people with HIV and those taking ARTs is needed in order to optimize cardiovascular prevention.”