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).
Primary/Secondary Keywords