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Evidence summaries

Angiotensin Receptor Blockers or Angiotensin Converting Enzyme Inhibitors in the Prevention of Atrial Fibrillation

Angiotensin converting enzyme inhibitors and angiotensin receptor blockers may be effective in the prevention of atrial fibrillation in patients with heart failure and hypertension. Level of evidence: "C"

A systematic review 1 included 7 studies with a total of 24 849 subjects. There was a significant difference in the development of atrial fibrillation (new-onset or recurrence post-cardioversion) in favour of treatment with ACEIs or ARBs compared with control (OR 0.57, 95% CI: 0.39 to 0.82). There was significant heterogeneity across the studies. A subgroup analysis of studies that included higher risk patients (those with left ventricular dysfunction or previous documented atrial fibrillation; n=7,250) showed that there was a significant benefit of treatment with ACEIs or ARBs compared with control (OR 0.42, 95% CI: 0.27 to 0.66).

A meta-analysis 2 on the effects of renin-angiotensin system (RAS) inhibition for the prevention of atrial fibrillation (AF) included 23 studies with a total of 87 048 subjects. Primary prevention studies: 6 studies in hypertension, 2 in myocardial infarction, and 3 in heart failure. Secondary prevention studies: 8 studies after cardioversion and 4 studies assessing the medical prevention of recurrence. Overall, treatment with an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB) reduced the OR of developing AF (primary and secondary prevention) by 33% (OR 0.67, 95% CI 0.57 to 0.78; statistical heterogeneity I2 =78%). 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% (OR 0.55, 95% CI 0.34 to 0.89) and in patients on medical therapy by 63% (OR 0.37, 95% CI 0.27 to 0.49).

Comment: The quality of evidence is downgraded by inconsistency (variability in results across studies) and by indirectness (combining ACEIs and ARBs in the meta-analysis may not be appropriate).

References

  • Madrid AH, Peng J, Zamora J, Marín I, Bernal E, Escobar C, Muños-Tinoco C, Rebollo JM, Moro C. The role of angiotensin receptor blockers and/or angiotensin converting enzyme inhibitors in the prevention of atrial fibrillation in patients with cardiovascular diseases: meta-analysis of randomized controlled clinical trials. Pacing Clin Electrophysiol 2004 Oct;27(10):1405-10. [PubMed]
  • Schneider MP, Hua TA, Böhm M, et al. Prevention of atrial fibrillation by Renin-Angiotensin system inhibition a meta-analysis. J Am Coll Cardiol 2010;55(21)2299-307. [PubMed]

Primary/Secondary Keywords