Beta-blockers independently associated with CVD, death in veterans with HIV
Among veterans with HIV and new-onset hypertension, beta-blockers were independently associated with increased risk for incident CVD or death compared with ACE inhibitors or angiotensin receptor blockers, researchers reported.
According to data published in Hypertension, neither calcium channel blockers nor diuretics were associated with elevated risk for incident CVD compared with ACE inhibitors or angiotensin receptor blockers.
“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,” 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 Philadelphia, said in a press release.
For this analysis, researchers included 8,041 veterans with HIV and incident hypertension (mean age, 53 years; 97% men; 49% Black) to determine whether antihypertensive class was associated with CVD events in that population. Outcomes of interest included incident/recurrent CVD or death, incident CVD and incident HF according to antihypertensive class. Median follow-up was 6.5 years.
Among the cohort, 24% were on ACE inhibitor or angiotensin receptor monotherapy, 23% were on thiazide or thiazide-like diuretic monotherapy, 13% were on beta-blocker monotherapy and 11% were on calcium channel blocker monotherapy.
“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 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. Ideally, a patient’s primary care and infectious disease team should work together for the best possible outcomes.”
CVD associated with antihypertensive class
During the study period, 25% of the cohort experienced a CVD event.
In the propensity-score matched analysis, beta-blockers were associated with increased risk for incident/recurrent CVD or death (HR = 1.54; 95% CI, 1.19-2), incident CVD or death (HR = 1.79; 955 CI, 1.31-2.44) and incident CVD (HR = 1.9; 95% CI, 1.24-2.89) but not incident HF (HR = 1.46; 95% CI, 0.98-2.19) compared with ACE inhibitors or angiotensin receptor blockers.
Neither calcium channel blockers (HR = 1.02; 95% CI, 0.77-1.34) nor diuretics (HR = 1.06; 95% CI, 0.86-1.31) were associated with any greater risk for incident CVD compared with ACE inhibitors/angiotensin receptor blockers.
Black, chronic kidney disease subgroup analysis
According to the study, beta-blockers, calcium channel blockers and diuretics were associated with increased risk for incident CVD or death compared with ACE inhibitors or angiotensin receptor blockers among non-Black individuals:
- HR for beta-blockers = 1.23; 95% CI, 1.03-1.48;
- HR for calcium channel blockers = 1.29; 95% CI, 1.01-1.65; and
- HR for diuretics = 1.4; 95% CI, 1.14-1.71.
However, researchers observed no increased risk for incident CVD or death among Black individuals on calcium channel blockers or diuretics compared with those initiated on ACE inhibitors or angiotensin receptor blockers.
Among patients with chronic kidney disease, calcium channel blockers and diuretics were associated with greater risk for incident CVD or death compared with ACE inhibitors or angiotensin receptor blockers (HR for calcium channel blockers = 1.79; 95% CI, 1.11-2.9; HR for diuretics = 2.4; 95% CI, 1.4-4.1).
“While mortality for people living with HIV has significantly improved with widespread availability of effective antiretroviral therapy, morbidity, and mortality from CVD remains higher than in the general population,” the researchers wrote. “Given the important links between blood pressure management and CVD, further research is needed to understand the mechanisms and clinical significance of treatment decisions around antihypertensive selection in this high-risk patient population.”