Study Calls for Change in Prescribing Practices of Antihypertensive Agents in Patients with HIV

Jordana Cohen, MD

A new study is calling for greater attention to treatment choices for managing high blood pressure among patients with human immunodeficiency virus (HIV).

With people with HIV at an increased risk of hypertension as a result of antiretroviral therapy (ART), results from the study suggesting many of these patients were not receiving guideline-recommended medications for treatment is seen as a major red flag among study investigators.

“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. 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,” said study investigator Jordana B. Cohen, MD, MSCE, assistant professor of medicine and epidemiology in the renal-electrolyte and hypertension division in the Perelman School of Medicine at the University of Pennsylvania, in a statement.

Thanks to advances in care and ART, patients with HIV have seen their life expectancies skyrocket in recent decades. However, a common result of ART is development of hypertension, which results in an increase in long-term risk of cardiovascular disease. Cohen and a team of colleagues designed their current analysis with the intent of using data from the Veterans Health Administration database to learn more about the interaction between use of certain blood pressure medications on risk of cardiovascular events in this population.

For the purpose of analysis, investigators identified veterans with HIV and incident hypertension using the database’s antihypertensives in obesity management cohort, which included more than 1 million veterans with incident hypertension from 2000-2018. Using propensity-score matching, investigators hoped to evaluate risk of incident and recurrent cardiovascular disease or death, incident cardiovascular disease, and incident heart failure stratified by antihypertensive class.

In total, investigators identified 8041 patients with HIV and incident hypertension for their analysis. Among these, 6516 did not have cardiovascular disease, peripheral arterial disease, or arrhythmia at baseline. The mean age of the study cohort was 53 (SD, 9 ) years, 97% were men, and 49% were Black.

At baseline, 74% of patients were receiving ART and 82% were initiated on antihypertensive monotherapy. The most common antihypertensive medications in the cohort were ACEs/ARBs (24%), diuretics (23%) beta-blockers (13%), and calcium channel blockers (11%). Over a median follow-up of 6.5 years, 25% of participants experienced a cardiovascular disease event and 27% died.

When compared to ACEs/ARBs, beta-blockers were associated with an increased risk of incident cardiovascular disease (HR, 1.90; 95% CI, 1.24-2.89). This increased risk was not seen among calcium channel blockers (HR, 1.02; 95% CI, 0.77-1.34) or diuretics (HR, 1.06; 95% CI, 0.86-1.31) when compared to ACEs/ARBs. Investigators noted similar risk was observed when using incident and recurrent cardiovascular disease or death as the primary outcome.

In subgroup analyses of veterans without chronic kidney disease, ACEs/ARBs were associated with a lower risk of incident heart failure when compared to the other drug classes included in the analyses.

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

This study, “Antihypertensive Class and Cardiovascular Outcomes in Patients With HIV and Hypertension,” was published in Hypertension.