Hypertension in HIV and Aging (Updated 8/30/17)

  • Hypertension remains one of the more common chronic diseases in older individuals and is associated with other chronic conditions such as cardiovascular disease, chronic kidney disease (CKD), and diabetes.
  • Most guidelines suggest that target BP for older individuals (age 60-79) should be below 150/90 mmHg.
  • Target BP for older adults with CKD or diabetes should be below 140/90 mmHg.
  • Specific data are not available that guide treatment of hypertension in individuals with HIV
  • Ambulatory blood pressure monitoring identifies individuals with hypertension who may have increased risk for complications.

Hypertension (HTN) remains of the more common chronic diseases in the general population, affecting nearly 75 million adults in the United States.[1] Recent studies have attempted to address the potential relationship between HIV infection, antiretroviral therapy (ART), and HTN. These reports [2-5] confirm that HTN is common; however, there is little evidence to suggest that HIV or ART by themselves cause HTN. Rather, as the population with HIV ages, the prevalence of HTN increases, just as it does in the general population. Risk factors such as chronic kidney disease (CKD), diabetes, and atherosclerotic heart disease also play a role.

Ambulatory blood pressure monitoring has revealed significant HTN, increasing throughout the day, particularly at night, in individuals that are normotensive or have medication-controlled hypertension in the clinic. Similar studies have confirmed these findings in individuals living with HIV, suggesting under-diagnosis of hypertension in this population.[6, 7]

Elevated nighttime blood pressure (BP) has been associated with increased risk for complications among individuals with hypertension, which has led to the recommendation that ambulatory monitoring should be routinely performed in individuals with HIV. [7]

As the number of individuals living with HIV has grown, many of them have begun to utilize healthcare services outside of HIV clinics. [8] The number of comorbidities has increased, particularly in those over the age of 50, and treatment for HTN has become common. These findings underscore the need for increased coordination of services, particularly for older individuals living with HIV. [8]

Treatment

There are several clinical guidelines for management of HTN, including guidelines published by the American College of Physicians (ACP) and the American Academy of Family Medicine (AAFP), the Eighth Joint National Committee (JNC8), and the AHA/ACC/ASH guidelines published by the American Heart Association, American College of Cardiology, and American Society of Hypertension. [9-11] Recommendations have also been published for target BP goals in the setting of different comorbid conditions, such as diabetes and CKD. [12, 13] These guidelines differ slightly in their recommendation for when to initiate therapy and the target BP for older adults diagnosed with HTN. The JNC8, AAFP and ACP advocate for target BP goals of less than 150/90mmHg for adults age 60 or older. The AHA/ACC/ASH recommend a slightly more aggressive target of less than 140/90mmHg for adults up through age 79 years.

For individuals with chronic conditions such as cardiovascular disease, stroke, diabetes, and CKD, most guidelines recommend BP targets less than 140/90 mmHg. Recommendations from KDIGO (Kidney Disease: Improving Global Outcomes) suggest that individuals with an eGFR less than 60 ml/min and urinary albumin excretion greater than 300 mg/day should have a target BP of less than 130/80mmHg. [13]

The Systolic Blood Pressure Intervention Trial (SPRINT) assessed if lowering systolic BP to less than 120mmHg versus less than 140mmHg was associated with improved outcomes in community dwelling adults age 50 or older. Data from this trial suggests that lower systolic BP may be beneficial for some individuals, such as those with pre-existing cardiovascular disease.[14] However, a more recent meta-analysis suggests that there is still limited evidence on the benefit of more intensive BP control in the general population.[15]  The recommendation that older persons should have a higher target systolic BP (150 vs. 140mmHg in younger persons) grew out of the recognition that older persons were more susceptible to orthostatic hypotension, changes in kidney function, and other side effects when attempts were made to adjust drug doses to achieve target goals. [14]

As noted in the JNC8 report, guidelines are not a substitute for careful clinical judgment, particularly in complex patients with competing risks. Target goals may not be achieved in individuals who develop complications of treatment.

There are no specific guidelines for the management of HTN in persons living with HIV (PLWH) that differ from those recommendations for the general population, but variations in guidelines for older individuals and those with CKD must be considered where appropriate. [2] Since the prevalence of CKD in PLWH is common, and inadequately treated BP is both a complication of CKD and a contributor to the rate of loss of kidney function, special attention to blood pressure management is usually required in this population.

There is evidence that the use of angiotensin-converting enzyme inhibitors (ACEI) and/or angiotensin receptor blockers (ARB) provide reno-protective benefits beyond lowering of blood pressure. This supports arguments that ACEI or ARB be considered as first-line choices in the treatment of hypertension in HIV-infected individuals with CKD. [10, 13] The use of these agents may also be effective in older individuals traditionally thought to have low renin states. Although the risk for hyperkalemia is increased with their use, particularly in individuals with reductions in GFR, with appropriate monitoring, they are safe and effective in most individuals.

Despite efforts to control HTN, standard therapies can fail to achieve target goals, particularly in complex patients with multiple co-morbidities. In patients where goal blood pressures are not achieved, clinicians should consider and assess for possible causes such as non-adherence to prescribed therapies or existence of secondary causes of hypertension (such as obstructive sleep apnea or primary aldosteronism). Recent studies have demonstrated the existence of benefits from the use of mineralocorticoid antagonists (spironolactone), particularly in refractory hypertension. [16]

Clinical trials evaluating the safety and efficacy of renal nerve ablation for the treatment of HTN where pharmacological management was not possible or ineffective have been instituted. Initial reports appeared promising , however additional experience is needed before recommendations regarding this therapy can be made for the management of refractory HTN. [17]

References

  1. Centers for Disease Control and Prevention. High Blood Pressure Facts. 2016. https://www.cdc.gov/bloodpressure/facts.htm
  2. Nguyen KA, Peer N, Mills EJ, Kengne AP. Burden, Determinants, and Pharmacological Management of Hypertension in HIV-Positive Patients and Populations: A Systematic Narrative Review. AIDS reviews 2015; 17(2):83-95.
  3. Tripathi A, Jerrell JM, Skelton TN, Nickels MA, Duffus WA. Incidence of primary hypertension in a population-based cohort of HIV-infected compared with non-HIV-infected persons and the effect of combined antiretroviral therapy. J Am Soc Hypertens 2015; 9(5):351-357.
  4. Okeke NL, Davy T, Eron JJ, Napravnik S. Hypertension Among HIV-infected Patients in Clinical Care, 1996-2013. Clin Infect Dis 2016; 63(2):242-248.
  5. Martin-Iguacel R, Negredo E, Peck R, Friis-Moller N. Hypertension Is a Key Feature of the Metabolic Syndrome in Subjects Aging with HIV. Curr Hypertens Rep 2016; 18(6):46.
  6. Kent ST, Bromfield SG, Burkholder GA, Falzon L, Oparil S, Overton ET, et al. Ambulatory Blood Pressure Monitoring in Individuals with HIV: A Systematic Review and Meta-Analysis. PLoS One 2016; 11(2):e0148920.
  7. Nuernberg M, Lang S, Curjol A, Haddour N, Ederhy S, Asri CE, et al. 1b.08: Usefulness of 24-Hour Ambulatory Blood Pressure Monitoring in People Living with Hiv. J Hypertens 2015; 33 Suppl 1:e7
  8. Patel R, Moore T, Cooper V, McArdle C, Perry N, Cheek E, et al. An observational study of comorbidity and healthcare utilisation among HIV-positive patients aged 50 years and over. Int J STD AIDS 2016; 27(8):628-637.
  9. Kansagara D, Wilt TJ, Frost J, Qaseem A. Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older. Ann Intern Med 2017; 167(4):291-292..
  10. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Jama 2014; 311(5):507-520.
  11. Rosendorff C, Lackland DT, Allison M, Aronow WS, Black HR, Blumenthal RS, et al. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. Hypertension 2015; 65(6):1372-1407.
  12. ADA. Cardiovascular Disease and Risk Management. Diabetes Care 2017; 40(Suppl 1):S75-S87.
  13. KDIGO. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. 2013. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. In: Kidney International; 2013. pp. 1-150.
  14. Sprint Research Group, Wright JT, Jr., Williamson JD, Whelton PK, Snyder JK, Sink KM, et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015; 373(22):2103-2116.
  15. Weiss J, Freeman M, Low A, Fu R, Kerfoot A, Paynter R. Benefits and Harms of Intensive Blood Pressure Treatment in Adults Aged 60 Years or Older. Annals of Internal Medicine 2017.
  16. Glicklich D, Frishman WH. Drug therapy of apparent treatment-resistant hypertension: focus on mineralocorticoid receptor antagonists. Drugs 2015; 75(5):473-485.
  17. Chen C, Upadhyay A. Renal denervation for uncontrolled hypertension: critical review of the evidence. Curr Opin Nephrol Hypertens 2016.
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