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Karakasis P, Patoulias D, Popovic DS, Pamporis K, Theofilis P, Nasoufidou A, Stachteas P, Samaras A, Tzikas A, Giannakoulas G, Stavropoulos G, Kassimis G, Karamitsos T, Fragakis N. Effects of mineralocorticoid receptor antagonists on new-onset or recurrent atrial fibrillation: a Bayesian and frequentist network meta-analysis of randomized trials. Curr Probl Cardiol 2024; 49:102742. [PMID: 39002620 DOI: 10.1016/j.cpcardiol.2024.102742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 07/10/2024] [Indexed: 07/15/2024]
Abstract
Background Clinical and translational research suggests that mineralocorticoid receptor antagonists (MRAs) may prevent atrial fibrosis and electrical remodeling associated with atrial fibrillation (AF). This study aimed to consolidate existing evidence from randomized controlled trials (RCTs) evaluating the effect of MRAs on incident or recurrent AF. Methods Medline, Cochrane Library and Scopus were searched until February 12, 2024. Triple-independent study selection, data extraction and quality assessment were performed. Evidence was pooled using both pairwise and Bayesian and frequentist network meta-analyses. Results Twenty-three RCTs (13,358 participants) were identified. Based on the pairwise random effects meta-analysis, MRAs were associated with a significant reduction in AF events compared to placebo or usual care (risk ratio {RR}= 0.75; 95% confidence interval {CI}= [0.66, 0.87]; P< 0.001; I2= 3%). This protective effect was robust both for new-onset and recurrent AF episodes (subgroup p-value= 0.69), while the baseline HF status was not a significant effect modifier (subgroup p-value= 0.58). MRAs demonstrated a significantly higher reduction in AF events for patients with chronic renal disease compared to placebo (RR= 0.78; 95% CI= [0.62, 0.98]; P= 0.03; I2= 0%). The network meta-analyses revealed that only spironolactone was associated with a significant reduction in AF events (Bayesian RR= 0.76; 95% CI= [0.65, 0.89]; P< 0.001; level of evidence moderate; SUCRA 0.731), while eplerenone and finerenone showed a neutral effect. Conclusion MRAs confer a significant benefit in terms of reducing incident or recurrent AF episodes, irrespective of HF status. In this context, spironolactone may be preferable compared to eplerenone or finerenone.
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Affiliation(s)
- Paschalis Karakasis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece.
| | - Dimitrios Patoulias
- Outpatient Department of Cardiometabolic Medicine, Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Djordje S Popovic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Centre of Vojvodina, Medical Faculty, University of Novi Sad, Novi Sad, Serbia
| | - Konstantinos Pamporis
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Panagiotis Theofilis
- First Cardiology Department, General Hospital of Athens "Hippocratio", University of Athens Medical School, Athens, Greece
| | - Athina Nasoufidou
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Panagiotis Stachteas
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Athanasios Samaras
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Apostolos Tzikas
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece; European Interbalkan Medical Center, Department of Cardiology, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, Aristotle University Medical School, Thessaloniki, AHEPA University General Hospital, Greece
| | - George Stavropoulos
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - George Kassimis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Theodoros Karamitsos
- First Department of Cardiology, Aristotle University Medical School, Thessaloniki, AHEPA University General Hospital, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
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Oraii A, Healey JS, Kowalik K, Pandey AK, Benz AP, Wong JA, Conen D, McIntyre WF. Mineralocorticoid receptor antagonists and atrial fibrillation: a meta-analysis of clinical trials. Eur Heart J 2024; 45:756-774. [PMID: 38195054 DOI: 10.1093/eurheartj/ehad811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/05/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND AND AIMS Mineralocorticoid receptor antagonists (MRAs) improve cardiovascular outcomes in a variety of settings. This study aimed to assess whether cardioprotective effects of MRAs are modified by heart failure (HF) and atrial fibrillation (AF) status and to study their impact on AF events. METHODS MEDLINE, Embase, and Cochrane Central databases were searched to 24 March 2023 for randomized controlled trials evaluating the efficacy of MRAs as compared with placebo or usual care in reducing cardiovascular outcomes and AF events in patients with or at risk for cardiovascular diseases. Random-effects models and interaction analyses were used to test for effect modification. RESULTS Meta-analysis of seven trials (20 741 participants, mean age: 65.6 years, 32% women) showed that the efficacy of MRAs, as compared with placebo, in reducing a composite of cardiovascular death or HF hospitalization remains consistent across patients with HF [risk ratio = 0.81; 95% confidence interval (CI): 0.67-0.98] and without HF (risk ratio = 0.84; 95% CI: 0.75-0.93; interaction P = .77). Among patients with HF, MRAs reduced cardiovascular death or HF hospitalization in patients with AF (hazard ratio = 0.95; 95% CI: 0.54-1.66) to a similar extent as in those without AF (hazard ratio = 0.82; 95% CI: 0.63-1.07; interaction P = .65). Pooled data from 20 trials (21 791 participants, mean age: 65.2 years, 31.3% women) showed that MRAs reduce AF events (risk ratio = 0.76; 95% CI: 0.67-0.87) in both patients with and without prior AF. CONCLUSIONS Mineralocorticoid receptor antagonists are similarly effective in preventing cardiovascular events in patients with and without HF and most likely retain their efficacy regardless of AF status. Mineralocorticoid receptor antagonists may also be moderately effective in preventing incident or recurrent AF events.
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Affiliation(s)
- Alireza Oraii
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - Krzysztof Kowalik
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Avinash K Pandey
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
| | - Jorge A Wong
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - David Conen
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - William F McIntyre
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
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Al-Hashedi EM, Abdu FA. Aldosterone Effect on Cardiac Structure and Function. Curr Cardiol Rev 2024; 20:60-67. [PMID: 38425104 PMCID: PMC11327832 DOI: 10.2174/011573403x281390240219063817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/18/2024] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Cardiac remodelling could be a key mechanism in aldosteronemediated cardiovascular morbidity and mortality. Experimental and clinical evidence has demonstrated that aldosterone causes cardiac structural remodelling and dysfunction by its profibrotic and pro-hypertrophic effects, which result mainly from the direct effects on myocardial collagen deposition, inflammation, and oxidative stress. Clinical studies have investigated the aldosterone effects on the heart in different clinical conditions, including general population, essential hypertension, primary aldosteronism, heart failure, and atrial fibrillation. Robust findings indicate that aldosterone or the activation of the cardiac mineralocorticoid receptor can cause damage to myocardial tissue by mechanisms independent of the blood pressure, leading to tissue hypertrophy, fibrosis, and dysfunction. CONCLUSION Aldosterone-mediated cardiovascular morbidity and mortality mainly result from cardiac structural and functional alterations. In different clinical settings, aldosterone can induce cardiac structural remodelling and dysfunction via several pathological mechanisms, including cardiac fibrosis, inflammation, and oxidative stress. Aldosterone antagonists could effectively decrease or reverse the detrimental aldosterone-mediated changes in the heart.
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Affiliation(s)
- Ekhlas Mahmoud Al-Hashedi
- Department of Internal Medicine, Faculty of Medicine and Health Sciences, Sana'a University, Sana'a, Yemen
- Department of Cardiology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Fuad A Abdu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
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Fatima K, Asad D, Shaikh N, Ansari SA, Kumar G, Rehman HA, Azam F, Khan SA, Ahmed S, Shah A, Bawani AM, Noorani A, Rashid AM. A Systematic Review and Meta-Analysis on Effectiveness of Mineralocorticoid Receptor Antagonists in Reducing the Risk of Atrial Fibrillation. Am J Cardiol 2023; 199:85-91. [PMID: 37269781 DOI: 10.1016/j.amjcard.2023.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/10/2023] [Accepted: 04/22/2023] [Indexed: 06/05/2023]
Abstract
Mineralocorticoid receptor antagonists (MRAs) are known to improve clinical outcomes in heart failure, particularly heart failure with reduced ejection fraction. However, the effect of MRAs on the incidence of and recurrence of atrial fibrillation (AF) is not well established. Therefore, databases, such as PubMed, EMBASE, and Cochrane Central, were searched from inception to September 2021 for randomized controlled trials of MRAs with AF as an outcome. Risk ratios (RRs) with 95% confidence interval (CIs) were combined using the random-effects model. A total of 10 randomized controlled trials (n = 11,356) were included. Our pooled analysis demonstrates that MRAs reduce the risk of AF occurrence by 23% compared with the control therapy (RR 0.77, 95% CI 0.65 to 0.91, p = 0.003, I2 = 40%). Subgroup analysis demonstrated that MRAs reduced the risk of both new-onset AF (RR 0.84, 95% CI 0.61 to 1.16, p = 0.28, I2 = 43%) and recurrent AF (RR 0.73, 95% CI 0.59 to 0.90, p = 0.004, I2 = 26%) similarly; p interaction = 0.48. Our meta-analysis concludes that MRAs reduce the risk of development of AF overall, with consistent effects in new-onset and recurrent AF.
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Affiliation(s)
- Kaneez Fatima
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Dayab Asad
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Nafhat Shaikh
- Department of Medicine, Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan.
| | - Saad Ali Ansari
- Department of Medicine, University of California, Riverside School of Medicine. Riverside, California
| | - Ganesh Kumar
- Department of Medicine, Chandka Medical College, Larkana, Pakistan
| | | | - Fatima Azam
- Department of Medicine, Dow International Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Shabitul Aisha Khan
- Department of Medicine, Dow International Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Sehar Ahmed
- Department of Medicine, Ziauddin Medical College, Karachi, Pakistan
| | - Arhama Shah
- Department of Medicine, Ziauddin Medical College, Karachi, Pakistan
| | | | - Amber Noorani
- Department of Biochemistry, Jinnah Sindh Medical University, Karachi, Pakistan
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Wang W, Chen Q, Zhang F, Chen X, Xu Z, Sun X, Li J, Chen L, Chen J. Radiofrequency catheter ablation combined with spironolactone in the treatment of atrial fibrillation: A single-center randomized controlled study. Clin Cardiol 2021; 44:1120-1127. [PMID: 34076288 PMCID: PMC8364720 DOI: 10.1002/clc.23659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 04/29/2021] [Accepted: 05/12/2021] [Indexed: 12/19/2022] Open
Abstract
At present, the question of whether radiofrequency ablation (RFA) combined with spironolactone can reduce the levels of plasma angiotensin II (AngII) and aldosterone (ALD) in patients with atrial fibrillation (AF) and reduce the recurrence of AF has not been reported.
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Affiliation(s)
- Weiwei Wang
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
| | - Quanhe Chen
- Union Clinic Medical College, Fujian Medical University, Fuzhou, China
| | - Feilong Zhang
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
| | - Xuehai Chen
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
| | - Zhe Xu
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
| | - Xudong Sun
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
| | - Jinguo Li
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
| | - Lianglong Chen
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
| | - Jianhua Chen
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
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