Prevention of Atrial Fibrillation by Renin-Angiotensin System Inhibition: A Meta-Analysis

doi:10.1016/j.jacc.2010.01.043

Journal of the American College of Cardiology

Volume 55, Issue 21, 25 May 2010, Pages 2299-2307

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Objectives

The authors reviewed published clinical trial data on the effects of renin-angiotensin system (RAS) inhibition for the prevention of atrial fibrillation (AF), aiming to define when RAS inhibition is most effective.

Background

Individual studies examining the effects of RAS inhibition on AF prevention have reported controversial results.

Methods

All published randomized controlled trials reporting the effects of treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in the primary or secondary prevention of AF were included.

Results

A total of 23 randomized controlled trials with 87,048 patients were analyzed. In primary prevention, 6 trials in hypertension, 2 trials in myocardial infarction, and 3 trials in heart failure were included (some being post-hoc analyses of randomized controlled trials). In secondary prevention, 8 trials after cardioversion and 4 trials assessing the medical prevention of recurrence were included. Overall, RAS inhibition reduced the odds ratio for AF by 33% (p < 0.00001), but there was substantial heterogeneity among trials. In primary prevention, RAS inhibition was effective in patients with heart failure and those with hypertension and left ventricular hypertrophy but not in post-myocardial infarction patients overall. In secondary prevention, RAS inhibition was often administered in addition to antiarrhythmic drugs, including amiodarone, further reducing the odds for AF recurrence after cardioversion by 45% (p = 0.01) and in patients on medical therapy by 63% (p < 0.00001).

Conclusions

This analysis supports the concept of RAS inhibition as an emerging treatment for the primary and secondary prevention of AF but acknowledges the fact that some of the primary prevention trials were post-hoc analyses. Further areas of uncertainty include potential differences among specific RAS inhibitors and possible interactions or synergistic effects with antiarrhythmic drugs.

Key Words

atrial fibrillation

angiotensin

angiotensin type 1 receptor

angiotensin-converting enzyme inhibitors

renin-angiotensin system

Abbreviations and Acronyms

ACEI

angiotensin-converting enzyme inhibitor

atrial fibrillation

ARB

angiotensin receptor blocker

confidence interval

ECG

electrocardiography

myocardial infarction

odds ratio

RAS

renin-angiotensin system

RCT

randomized controlled trial

Cited by (0)

: Dr. Schneider received lecture fees from Novartis Pharmaceuticals Corporation. Dr. Hua is an employee of Novartis Pharmaceuticals Corporation. Prof. Böhm served on the steering committees of the ONTARGET (Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial) and TRANSCEND (Telmisartan Randomized Assessment Study in ACE Intolerant Subjects With Cardiovascular Disease) trials and is supported by Deutsche ForschungsgemeinschaftKFO 196(Clinical Research Unit on Signal Transduction in Adaptive and Maladaptive Cardiac Remodelling, Bonn, Germany). Dr. Wachtell received lecture fees from AstraZeneca, Merck & Company, Inc., and Novartis Pharmaceuticals Corporation and serves on the advisory board of Merck & Company, Inc. Prof. Kjeldsen has received lecture fees from AstraZeneca, Bayer AG, Boehringer Ingelheim GmbH, Menarini, Merck & Company, Inc., Novartis Pharmaceuticals Corporation, Pfizer, Inc., Daiichi Sankyo, Sanofi-Aventis, and Servier Laboratories. Prof. Schmieder received lecture fees from Asche Chiesi, AstraZeneca, Bayer AG, Boehringer Ingelheim GmbH, Daiichi Sankyo, Menarini, Novartis Pharmaceuticals Corporation, Sanofi-Aventis, Servier, Takeda, Merck Sharp & Dohme, and Bristol-Myers Squibb; and has received research support for clinical trials from DFG, Bristol-Myers Squibb, Merck Sharp & Dohme, Novartis, Takeda, AstraZeneca, Boehringer Ingelheim, and Roche.