HIV and High Blood Pressure: It's Complicated

For people with HIV and high blood pressure, the type of medication used to lower their blood pressure may impact future cardiovascular risk, new research shows.

The study, published Monday in the American Heart Association journal Hypertension, found certain blood pressure medications increased the risk for heart disease, stroke or heart failure while others lowered the risk of heart failure in a group of mostly male veterans.

With current anti-retroviral medications, people with HIV are able to live longer. However, people taking these medications are more likely to develop high blood pressure and related heart problems than people in the general population. This is the first large-scale study to examine how the choice of blood pressure medication influences the long-term risk of heart disease, stroke and heart failure in people with HIV and high blood pressure.

Researchers reviewed the records of 8,041 veterans with HIV who developed high blood pressure between 2000 and 2018. As a first treatment, 13% were prescribed beta blockers; 24% were started with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs); 23% were given thiazide or similar diuretics; and 11% were prescribed calcium channel blockers (CCBs).

Participants without heart disease at the beginning of the study who were prescribed beta blockers had a 90% higher risk of developing heart disease, heart failure or stroke during an average 6.5 years of follow-up than those given ACE inhibitors or ARBs, even if their blood pressure was well controlled. Thiazide diuretics and CCBs did not increase risk.

Among participants without chronic kidney disease, taking ACE inhibitors or ARBs was associated with a lower risk of heart failure compared to taking other blood pressure medications, which increased the risk of developing heart failure by about 50%.

The study's senior author Dr. Jordana Cohen said in a news release the choice of blood pressure medication participants were prescribed could have varied due to potential drug interactions with HIV medications. Cohen is an assistant professor of medicine and epidemiology in the renal-electrolyte and hypertension division at the University of Pennsylvania Perelman School of Medicine in Philadelphia.

"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," she said.

Cohen said it was unusual to find such high use of beta blockers since they are not typically recommended as the first line of treatment for high blood pressure.

"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," Cohen said. "Ideally, a patient's primary care and infectious disease teams work together for the best possible outcomes."

Cohen said the results also highlight possible harm from using beta blockers as first-line treatment for hypertension whether a person has HIV or not.

"While many people are appropriately treated with beta blockers for various reasons," she said, "if you think you are taking them only for hypertension and aren't on any other blood pressure medications, I'd recommend talking to your doctor to make sure it's the best medication for you."