A systematic review 1 including 8 studies with a total of 15616 subjects was abstracted in DARE. 4 studies appear to be RCTs and 4 were described as post hoc analyses of large clinical trials. Patients treated with an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) had reduced occurrence of new-onset atrial fibrillation (AF) in comparison with either placebo or active comparator (OR 0.51, 95% CI 0.36 to 0.72; 4 studies, n=14826). All included patients had some degree of left ventricular dysfunction (the degree varied between studies).
Patients pre-treated with an ACE inhibitor or ARB were less likely to fail direct current cardioversion (DCC) than patients who did not receive any pre-treatment (OR 0.47, 95% CI 0.24 to 0.92; 4 studies, n=387). A subgroup analysis of only those studies in which ACE inhibitors or ARBs were added to amiodarone also remained significant. Patients treated with an ACE inhibitor or ARB in addition to standard care demonstrated reduced rates of AF recurrence (OR 0.39, 95% CI 0.20 to 0.75; 4 studies, n=370). With the exception of the new-onset atrial fibrillation analysis, these findings were not associated with statistical heterogeneity. These hypothesis-generating data suggest that inhibitors of the renin-angiotensin system may provide benefit across the spectrum of atrial fibrillation.
Comment: The quality of evidence is downgraded by limitations in the review and study quality (study quality and study design not reported; the use of post hoc data in the new onset AF analysis) and by indirectness (most of the studies evaluated ACE inhibitors or ARBs in combination with amiodarone).
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