Renin-angiotensin-aldosterone system inhibitors and mortality risk in elderly patients with atrial fibrillation. Insights from the nationwide START registry

Long-Term Statin Use Is Associated With Reduced Rates of Adverse Events in Patients With Newly Diagnosed Atrial Fibrillation

BACKGROUND

The effectiveness of statin use in preventing adverse cardiovascular events in individuals with atrial fibrillation (AF) has remained uncertain. This study aimed to assess whether statin use could lead to better outcomes among individuals with AF.

METHODS AND RESULTS

We enrolled 397 787 patients with AF from January 1, 2012 to December 31, 2020. Patients with AF were divided into 2 groups (statin user and statin nonuser), and the risks of composite outcomes (including ischemic stroke, hemorrhagic stroke, and transient ischemic attack), all-cause death, and major adverse cardiovascular events (which encompassed cardiovascular death, myocardial infarction, stroke, and heart failure hospitalization) were analyzed. We analyzed 288 958 patients with newly diagnosed AF (mean age, 73 years; 44% women; mean CHA2DS2-VASc score, 3.5). Compared with patients without statin use, statin users had lower risks of composite end points (adjusted hazard ratio [HR], 0.91 [95% CI, 0.87-0.94]; P<0.01). In regard to all-cause death, statin users exhibited a 67% risk reduction compared with statin nonusers (adjusted HR, 0.33 [95% CI, 0.32-0.33]; P<0.01). Statin use was also associated with reduced incidence of major adverse cardiovascular events (adjusted HR, 0.64 [95% CI, 0.63-0.66]; P<0.01). In the subgroups stratified by CHA2DS2-VASc score, statin therapy was particularly effective for patients with CHA2DS2-VASc scores 0 to 3 for composite end points but consistently reduced all-cause mortality and major adverse cardiovascular events across all score categories.

CONCLUSIONS

Among patients with newly diagnosed AF, statin use was associated with lower risk of ischemic stroke, hemorrhagic stroke, transient ischemic attack, all-cause mortality, and major adverse cardiovascular events.

Relationship Between Screening-Detected Atrial Fibrillation and Blood Pressure Levels in Elderly Hypertensive Patients: The OMRON Heart Study

BACKGROUND

 Hypertension is a well-known risk factor for atrial fibrillation (AF) and strokes, but studies assessing screening-detected AF in hypertensive populations and its relationship to the blood pressure (BP) are scarce.

METHOD

 We prospectively recruited hypertensive patients (aged ≥60 years) from all over Japan in a decentralized clinical trial. Participants were asked to measure their electrocardiogram (ECG) and BP at home for 3 months with a BP monitor equipped with ECG.

RESULTS

 Between April 2022 and July 2023, 4,078 hypertensive patients from across the country participated in this study. The mean age was 66.3 ± 5.5 years, and the male proportion was 80.3%. After excluding those with no measurement data (n = 258), AF detection was 5.8% (n = 220/3,820), and the time to AF detection was 3 to 109 days (median 28 days). The mean BP at baseline was 133 ± 14/85 ± 9 mmHg in the morning and 125 ± 14/79 ± 9 mmHg in the evening. AF detection did not significantly differ between the baseline BP categories (log rank test, p = 0.54), with hazard ratios (95% confidence interval) of 0.83 (0.57-1.19), 0.79 (0.55-1.14), and 0.99 (0.59-1.68) for systolic BP (SBP) 135 to 144 and/or diastolic BP (DBP) 85 to 89, SBP 145 to 159 and/or DBP 90 to 99, and SBP ≥ 160 and/or DBP ≥ 100, respectively (SBP ≤ 134 and DBP ≤ 84 as a reference). The results did not change when taking into account the impact of the measurement rates and antihypertensive drugs on AF detection during the observation period.

CONCLUSION

 Detection of undiagnosed AF was 5.8% in elderly hypertensives, with no significant differences between the baseline BP categories and no effect of the measurement rate or antihypertensive drugs.

Cardiovascular medications used for comorbid diseases in patients with atrial fibrillation. The JoFib study

PURPOSE

Many atrial fibrillation (AF) patients use cardiovascular medications for indications other than AF. These medications can affect morbidity and mortality. We aim to investigate the characteristics of AF patients who use different medication classes and their clinical course.

METHODS

We collected data from the prospective, multicenter registry, JoFib study. We identified classes of non-AF medications (medications not used for rate control, rhythm control, or anticoagulation), described demographic and clinical characteristics, and investigated AF-related outcomes according to these medication classes.

RESULTS

From a total of 2020 patients, five classes of cardiovascular non-AF medications were identified, aspirin, P2Y12 inhibitors, ACE inhibitors/ARBs, statins, and diuretics. The most commonly used non-AF medications were diuretics and ACE inhibitors/ARBs (39.2%, and 39%, respectively). 51% of AF patients took more than one non-AF medication. Multivariable Cox regression analysis demonstrated that ACE inhibitor/ARB therapy independently reduced the risks of all-cause mortality and cardiovascular mortality (aHR 0.50, 95%CI 0.37-0.68; aHR 0.51, 95%CI 0.34-0.75, respectively) and that statin therapy reduced the risk of cardiovascular mortality (aHR 0.68, 95%CI 0.48-0.98) in AF patients. Multivariable logistic regression analysis demonstrated a protective effect of statin therapy against the secondary outcome, clinically relevant non-major bleeding (CRNMB) (adjusted OR 0.62 95%CI 0.42-0.94).

CONCLUSION

Our findings suggest a protective effect of ACE inhibitors/ARBs against all-cause and cardiovascular mortality, statins against cardiovascular mortality, and CRNMB in patients with AF. Accordingly, these medications should be encouraged in patients with AF when indicated. Additionally, future research should explore whether these medications should be offered to AF patients more routinely. The study was registered with Clinicaltrials.gov (unique identifier number: NCT03917992, Registration date:14/4/2019).