Angiotensin receptor blockers or angiotensin converting enzyme inhibitors in the prevention of atrial fibrillation

Evidence Summaries

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

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

1. 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.  [PMID:15511250]
2. 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.  [PMID:20488299]

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