Philadelphia, PA—Choice of high blood pressure (BP) medication can make a critical difference for human immunodeficiency virus (HIV) patients, according to a new study.

The type of medication chosen for their initial treatment could influence risk of heart disease, stroke and heart failure, according to the study in Hypertension, an American Heart Association journal.

The issue is especially important because patients receiving antiretroviral therapy (ART) are more likely to develop hypertension and related cardiac issues than those who do not have HIV, according to authors from the Perelman School of Medicine at the University of Pennsylvania and colleagues.

Researchers tout their study as the first to examine how the choice of blood pressure medications influences the long-term risk of heart disease, stroke, and heart failure in the HIV positive population with a higher risk of cardiovascular disease (CVD).

“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,” explained lead author Jordana B. Cohen, MD. “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.”

Among veterans with HIV and incident hypertension using 2000–2018 records, they evaluated risk of (1) incident/recurrent CVD or death, (2) incident CVD, and (3) incident heart failure by antihypertensive class. Among 8,041 patients:
• 24% were initiated on angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) monotherapy
• 23% on thiazide/thiazide-like diuretic monotherapy
• 13% on beta-blocker monotherapy
• 11% on calcium channel blocker monotherapy.

Researchers report that, over a median of 6.5 years, 25% experienced a CVD event, adding, “Beta-blockers, but not calcium channel blockers or diuretics, were associated with an increased risk of incident CVD compared with ACEs/ARBs (hazard ratio [95% CI], beta-blockers 1.90 [1.24–2.89]; calcium channel blockers 1.02 [0.77–1.34]; diuretics 1.06 [0.86–1.31]); similar hazard ratio were noted for incident/recurrent CVD or death.”

Study participants were aged 53 years on average, were 97% male, and 49% Black adults.

The report adds that, in veterans without chronic kidney disease, ACE inhibitor/ARBs were associated with a lower risk of incident heart failure compared with all other classes (hazard ratio [95% CI]: beta-blockers, 1.52 [1.11-.09]; calcium channel blockers 1.48 [1.00-2.19]; diuretics 1.52 [1.07-2.16]).

“In conclusion, we observed high rates of CVD events in people with HIV with hypertension and a high prevalence of beta-blocker use for initial hypertension management, even among those without indications,” the authors write. “Our findings highlight the potential harm associated with beta-blockers and the possible benefit associated with ACE inhibitor/ARBs for hypertension management in people with HIV. Prospective and randomized trials are needed to confirm these findings.”

“Blood pressure and heart disease risk in patients who have HIV can be safely managed with first-line treatment of hypertension with ACEis, ARBs, CCBs and thiazide diuretics and may have added benefit from initial treatment with ACEis and ARBs,” Dr. Cohen added.

The authors pointed out an unusual trend in the group: Although CCBs are among the medications recommended for the initial treatment of hypertension, beta-blockers were prescribed more frequently than CCBs in this study.

“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,” Dr. Cohen said. “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. Ideally, a patient’s primary care and infectious disease team should work together for the best possible outcomes.”

She raised concerns of possible harm from using beta-blockers as first-line treatment for hypertension despite HIV status.

“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,” Dr. Cohen said.

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