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Yang L, Chung MK. Lifestyle changes in atrial fibrillation management and intervention. J Cardiovasc Electrophysiol 2023; 34:2163-2178. [PMID: 36598428 PMCID: PMC10318120 DOI: 10.1111/jce.15803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 12/13/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023]
Abstract
Atrial fibrillation (AF) is one of the most common arrhythmias in adults, and its continued rise in the United States is complicated by the increased incidence and prevalence of several AF risk factors, such as obesity, physical inactivity, hypertension, obstructive sleep apnea, diabetes mellitus, coronary artery disease, and alcohol, tobacco, or caffeine use. Lifestyle and risk factor modification has been proposed as an additional pillar of AF therapy, added to rhythm control, rate control, and anticoagulation, to reduce AF burden and risk. Although emerging evidence largely supports the integration of lifestyle and risk factor management in clinical practice, randomized clinical trials investigating the long-term sustainability and reproducibility of these benefits remain sparse. The purpose of this review is to discuss potentially reversible risk factors on AF, share evidence for the impact on AF by modification of these risk factors, and then provide an overview of the effects of reversing or managing these risk factors on the success of various AF management strategies, such as antithrombotic, rate control, and rhythm control therapies.
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Affiliation(s)
- Lucy Yang
- The Departments of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, and Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Mina K Chung
- The Departments of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, and Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Rivard L, Samuel M, Fortier A, Guertin MC, Khairy P, Roy D, Talajic M, Tardif JC. Effect of Perindopril on Atrial Fibrillation Recurrence and Burden: Results of the Canadian Trial of Atrial Fibrillation (CTAF)-2. CJC Open 2021; 3:1100-1107. [PMID: 34712936 PMCID: PMC8531231 DOI: 10.1016/j.cjco.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/26/2021] [Indexed: 11/24/2022] Open
Abstract
Background Hypertension is a risk factor for the development and exacerbation of atrial fibrillation (AF). Angiotensin-converting enzyme inhibitors are a standard-of-care treatment option for patients with hypertension; however, there is conflicting evidence about their effects on AF recurrence. Therefore, our objective was to assess the efficacy of perindopril, compared with placebo, to reduce AF recurrence in patients with hypertension and AF. Methods In a multicenter, double-blind, placebo-controlled trial, patients with hypertension and symptomatic AF were randomly assigned (1:1) to perindopril or placebo based on a stratification factor of antiarrhythmic drug use. Patients with terminated AF were followed up from 30 days after randomization to 7 to 13 months. The primary endpoint was AF recurrence. Secondary endpoints included AF hospitalization, cardioversion, and blood pressure control. Recurrent events, AF burden, and safety endpoints were also investigated. Results A total of 315 patients were randomly assigned, and 301 patients were included in the modified intent-to-treat analysis (155 vs 146 patients in the perindopril and placebo groups, respectively). The mean follow-up was 336 ± 70 days, and 91.1% of patients were compliant to the treatment medication throughout the study. After adjustment for baseline antiarrhythmic drugs, there was no statistically significant difference in the hazards of AF recurrence (hazard ratio, 1.22; 95% confidence interval, 0.92-1.61), with similar blood pressure. The incidence of secondary endpoints and adverse events also did not differ between treatment arms. Conclusions Perindopril does not reduce recurrence or the number of AF episodes in patients with hypertension and AF.
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Affiliation(s)
- Lena Rivard
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Michelle Samuel
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Annik Fortier
- Montreal Health Innovations Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Marie-Claude Guertin
- Montreal Health Innovations Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Paul Khairy
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Denis Roy
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Mario Talajic
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jean-Claude Tardif
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
- Corresponding author: Dr Jean-Claude Tardif, Montreal Heart Institute, 5000 Belanger Street, Montreal, Quebec H1T 1C8, Canada. Tel.: 514 376-3330; Fax: 514 376-1355.
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Mascolo A, Urbanek K, De Angelis A, Sessa M, Scavone C, Berrino L, Rosano GMC, Capuano A, Rossi F. Angiotensin II and angiotensin 1-7: which is their role in atrial fibrillation? Heart Fail Rev 2021; 25:367-380. [PMID: 31375968 DOI: 10.1007/s10741-019-09837-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Atrial fibrillation (AF) is a significant cause of morbidity and mortality as well as a public health burden considering the high costs of AF-related hospitalizations. Pre-clinical and clinical evidence showed a potential role of the renin angiotensin system (RAS) in the etiopathogenesis of AF. Among RAS mediators, angiotensin II (AII) and angiotensin 1-7 (A1-7) have been mostly investigated in AF. Specifically, the stimulation of the pathway mediated by AII or the inhibition of the pathway mediated by A1-7 may participate in inducing and sustaining AF. In this review, we summarize the evidence showing that both RAS pathways may balance the onset of AF through different biological mechanisms involving inflammation, epicardial adipose tissue (EAT) accumulation, and electrical cardiac remodeling. EAT is a predictor for AF as it may induce its onset through direct (infiltration of epicardial adipocytes into the underlying atrial myocardium) and indirect (release of inflammatory adipokines, the stimulation of oxidative stress, macrophage phenotype switching, and AF triggers) mechanisms. Classic RAS blockers such as angiotensin converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) may prevent AF by affecting the accumulation of the EAT, representing a useful therapeutic strategy for preventing AF especially in patients with heart failure and known left ventricular dysfunction. Further studies are necessary to prove this benefit in patients with other cardiovascular diseases. Finally, the possibility of using the A1-7 or ACE2 analogues, to enlarge current therapeutic options for AF, may represent an important field of research.
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Affiliation(s)
- Annamaria Mascolo
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, University of Campania "Luigi Vanvitelli", Via Santa Maria di Costantinopoli 16, 80138, Naples, Italy.
| | - Konrad Urbanek
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, University of Campania "Luigi Vanvitelli", Via Santa Maria di Costantinopoli 16, 80138, Naples, Italy
| | - Antonella De Angelis
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, University of Campania "Luigi Vanvitelli", Via Santa Maria di Costantinopoli 16, 80138, Naples, Italy
| | - Maurizio Sessa
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, University of Campania "Luigi Vanvitelli", Via Santa Maria di Costantinopoli 16, 80138, Naples, Italy
| | - Cristina Scavone
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, University of Campania "Luigi Vanvitelli", Via Santa Maria di Costantinopoli 16, 80138, Naples, Italy
| | - Liberato Berrino
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, University of Campania "Luigi Vanvitelli", Via Santa Maria di Costantinopoli 16, 80138, Naples, Italy
| | - Giuseppe Massimo Claudio Rosano
- IRCCS San Raffaele Pisana, Rome, Italy.,Cardiovascular and Cell Sciences Research Institute, St. George's, University of London, London, UK
| | - Annalisa Capuano
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, University of Campania "Luigi Vanvitelli", Via Santa Maria di Costantinopoli 16, 80138, Naples, Italy
| | - Francesco Rossi
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, University of Campania "Luigi Vanvitelli", Via Santa Maria di Costantinopoli 16, 80138, Naples, Italy
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Williams EA, Russo V, Ceraso S, Gupta D, Barrett-Jolley R. Anti-arrhythmic properties of non-antiarrhythmic medications. Pharmacol Res 2020; 156:104762. [PMID: 32217149 PMCID: PMC7248574 DOI: 10.1016/j.phrs.2020.104762] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 03/10/2020] [Accepted: 03/17/2020] [Indexed: 02/06/2023]
Abstract
Traditional anti-arrhythmic drugs are classified by the Vaughan-Williams classification scheme based on their mechanisms of action, which includes effects on receptors and/or ion channels. Some known anti-arrhythmic drugs do not perfectly fit into this classification scheme. Other medications/molecules with established non-anti-arrhythmic indications have shown anti-arrhythmic properties worth exploring. In this narrative review, we discuss the molecular mechanisms and evidence base for the anti-arrhythmic properties of traditional non-antiarrhythmic drugs such as inhibitors of the renin angiotensin system (RAS), statins and polyunsaturated fatty acids (PUFAs). In summary, RAS antagonists, statins and PUFAs are 'upstream target modulators' that appear to have anti-arrhythmic roles. RAS blockers prevent the downstream arrhythmogenic effects of angiotensin II - the main effector peptide of RAS - and the angiotensin type 1 receptor. Statins have pleiotropic effects including anti-inflammatory, immunomodulatory, modulation of autonomic nervous system, anti-proliferative and anti-oxidant actions which appear to underlie their anti-arrhythmic properties. PUFAs have the ability to alter ion channel function and prevent excessive accumulation of calcium ions in cardiac myocytes, which might explain their benefits in certain arrhythmic conditions. Clearly, whilst a number of anti-arrhythmic drugs exist, there is still a need for randomised trials to establish whether additional agents, including those already in clinical use, have significant anti-arrhythmic effects.
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Affiliation(s)
- Emmanuel Ato Williams
- Department of Cardiology, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool, L14 3PE, United Kingdom; Institute of Aging and Chronic Disease, University of Liverpool, United Kingdom
| | - Vincenzo Russo
- Chair of Cardiology, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Naples, Italy
| | - Sergio Ceraso
- Specialization Fellow in Cardiology, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool, L14 3PE, United Kingdom
| | - Richard Barrett-Jolley
- Chair Neuropharmacology, Institute of Aging and Chronic Disease, University of Liverpool, United Kingdom.
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Nair GM, Nery PB, Redpath CJ, Birnie DH. The Role Of Renin Angiotensin System In Atrial Fibrillation. J Atr Fibrillation 2014; 6:972. [PMID: 27957054 DOI: 10.4022/jafib.972] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 02/26/2014] [Accepted: 02/28/2014] [Indexed: 01/23/2023]
Abstract
Atrial fibrillation (AF) is the most prevalent arrhythmia and its incidence is on the rise. AF causes significant morbidity and mortality leading to rising AF-related health care costs. There is experimental and clinical evidence from animal and human studies that suggests a role for the renin angiotensin system (RAS) in the etiopathogenesis of AF. This review appraises the current understanding of RAS antagonism, using angiotensin converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB) and aldosterone antagonists (AA), for prevention of AF. RAS antagonism has proven to be effective for primary and secondary prevention of AF in subjects with heart failure and left ventricular (LV) dysfunction.However, most of the evidence for the protective effect of RAS antagonism is from clinical trials that had AF as a secondary outcome or from unspecified post-hoc analyses. The evidence for prevention in subjects without heart failure and with normal LV function is not as clear. RAS antagonism, in the absence of concomitant antiarrhythmic therapy, was not shown to reduce post cardioversion AF recurrences. RAS antagonism in subjects undergoing catheter ablation has also been ineffective in preventing AF recurrences.
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Affiliation(s)
- Girish M Nair
- Arrhythmia Service, Division of Cardiology University of Ottawa Heart Institute 40 Ruskin Ave, Ottawa Canada - K1Y 4W7
| | - Pablo B Nery
- Arrhythmia Service, Division of Cardiology University of Ottawa Heart Institute 40 Ruskin Ave, Ottawa Canada - K1Y 4W7
| | - Calum J Redpath
- Arrhythmia Service, Division of Cardiology University of Ottawa Heart Institute 40 Ruskin Ave, Ottawa Canada - K1Y 4W7
| | - David H Birnie
- Arrhythmia Service, Division of Cardiology University of Ottawa Heart Institute 40 Ruskin Ave, Ottawa Canada - K1Y 4W7
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Marott SC, Nielsen SF, Benn M, Nordestgaard BG. Antihypertensive treatment and risk of atrial fibrillation: a nationwide study. Eur Heart J 2013; 35:1205-14. [DOI: 10.1093/eurheartj/eht507] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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Sengul C, Cevik C, Ozveren O, Oduncu V, Sunbul A, Kılıcarslan F, Semiz E, Dindar I. Telmisartan decreases atrial electromechanical delay in patients with newly diagnosed essential hypertension. J Electrocardiol 2012; 45:123-8. [DOI: 10.1016/j.jelectrocard.2011.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Indexed: 10/16/2022]
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Disertori M, Quintarelli S. Renin-Angiotensin System and AtrialFibrillation:Understanding the Connection. J Atr Fibrillation 2011; 4:398. [PMID: 28496706 DOI: 10.4022/jafib.398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 09/19/2011] [Accepted: 12/14/2011] [Indexed: 11/10/2022]
Abstract
Atrial fibrillation (AF) arises as a result of a complex interaction of triggers, perpetuators and the substrate. The recurrence of AF may be partially related to a biologic phenomenon known as remodeling, in which the electrical, mechanical, and structural properties of the atrial tissue and cardiac cells are progressively altered,creating a more favorable substrate. Atrial remodeling is in part a consequence of arrhythmia itself. Therefore,to prevent and to treat AF, much attention has been directed to upstream therapies to alter the arrhythmia substrate and to reduce atrial remodeling. The renin-angiotensin-aldosterone system (RAAS) plays a keyrole in these strategies. In this review we analyze the experimental and clinical evidence regarding the efficacy of RAAS inhibitors in AF treatment. In the primary prevention of AF, meta-analyses have shown that risk of new-onset AF in patients with congestive heart failure and left ventricular dysfunction is reduced by RAAS inhibitors, whereas in hypertensive and post-myocardial infarction patients, the results are less evident. In the secondary prevention of AF, some large, prospective, randomized, placebo-controlled studieswith angiotensin II-receptor blockers returned negative results. Unfortunately, the approach of using RAASinhibitors as antiarrhythmic drugs to prevent both new-onset and recurrent AF is in decline because negativetrial results are accumulating, with the exception of the results in patients with congestive heart failure.
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Hypertension and atrial fibrillation: epidemiology, pathophysiology and therapeutic implications. J Hum Hypertens 2011; 26:563-9. [PMID: 22129612 DOI: 10.1038/jhh.2011.105] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Hypertension is one of the most important risk factors associated with atrial fibrillation (AF) and increased the risk of cardiovascular events in patients with AF. However, the pathophysiological link between hypertension and AF is unclear. Nevertheless, this can be explained by the hemodynamic changes of the left atrium secondary to long standing hypertension, resulting in elevated left atrium pressure and subsequently left atrial enlargement. Moreover, the activation of renin-angiotensin-aldosterone system (RAAS) activation in patients with hypertension induces left atrial fibrosis and conduction block in the left atrium, resulting in the development of AF. Accordingly, recent studies have shown that effective blockage of RAAS by angiotensin converting enzyme inhibitors or angiotensin receptor antagonist may be effective in both primary and secondary prevention of AF in patients with hypertension, although with controversies. In addition, optimal antithrombotic therapy, blood pressure control as well as rate control for AF are key to the management of patients with AF.
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Disertori M, Barlera S, Staszewsky L, Latini R, Quintarelli S, Franzosi MG. Systematic Review and Meta-Analysis: Renin-Angiotensin System Inhibitors in the Prevention of Atrial Fibrillation Recurrences. An Unfulfilled Hope. Cardiovasc Drugs Ther 2011; 26:47-54. [DOI: 10.1007/s10557-011-6346-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Savelieva I, Kakouros N, Kourliouros A, Camm AJ. Upstream therapies for management of atrial fibrillation: review of clinical evidence and implications for European Society of Cardiology guidelines. Part II: secondary prevention. Europace 2011; 13:610-25. [PMID: 21515595 DOI: 10.1093/europace/eur023] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Fundamental research into molecular mechanisms of atrial fibrillation (AF) and improved understanding of processes involved in the initiation and maintenance of AF have transformed the traditional approach to its management by targeting only the electrical aspects, usually with antiarrhythmic drugs and, recently, by ablation. The antiarrhythmic potential of upstream therapies, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers (ARBs), statins, and n-3 (ω-3) polyunsaturated fatty acids, extends beyond the benefit of treating underlying heart disease to modifying the atrial substrate and intervening in specific mechanisms of AF. The key target is structural remodelling of the atria, particularly inflammation and fibrosis, although there is evidence to suggest the direct involvement at the ion channel level. Positive clinical reports supported by robust experimental data have suggested that upstream therapies can be valuable strategies for primary prevention of AF in selected patients and have resulted in several class IIA recommendations in the new European guidelines on AF. However, these results have not been consistently replicated in the secondary prevention setting, and several recent randomized controlled studies failed to demonstrate any effect of upstream therapies on AF burden or on major cardiovascular outcomes. Part II of the review summarizes the evidence base for the use of upstream therapies for secondary prevention of AF.
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Affiliation(s)
- Irene Savelieva
- Division of Cardiac and Vascular Sciences, St George's University of London, London SW17 0RE, UK.
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Reviewing the future of renin-angiotensin system blockade: the role of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in the prevention of atrial fibrillation. Can J Cardiol 2011; 26 Suppl E:21E-23E. [PMID: 21620287 DOI: 10.1016/s0828-282x(10)71170-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 09/04/2010] [Indexed: 11/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice, affecting approximately 250,000 Canadians and accounting for more than 120,000 hospitalizations each year. Atrial remodelling, which is at least partially induced by activation of the renin-angiotensin system (RAS), can be reversed by RAS blockade using angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. While RAS antagonists are not considered to be conventional anti-arrhythmic agents, several studies have shown that they may reduce the incidence of AF in patients with heart failure, after myocardial infarction with reduced ejection fraction, and in hypertensive patients. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have also been used in association with amiodarone to facilitate sinus rhythm maintenance after electrical cardioversion. Whether RAS blockade prevents recurrent AF in patients at high cardiovascular risk remains unknown.
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Zografos T, Katritsis DG. Inhibition of the renin-angiotensin system for prevention of atrial fibrillation. Pacing Clin Electrophysiol 2011; 33:1270-85. [PMID: 20636314 DOI: 10.1111/j.1540-8159.2010.02832.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation (AF) is a source of considerable morbidity and mortality. There has been compelling evidence supporting the role of renin-angiotensin system (RAS) in the genesis and perpetuation of AF through atrial remodeling, and experimental studies have validated the utilization of RAS inhibition for AF prevention. This article reviews clinical trials on the use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) for the prevention of AF. Results have been variable, depending on the clinical background of treated patients. ACEIs and ARBs appear beneficial for primary prevention of AF in patients with heart failure, whereas they are not equally effective in hypertensive patients with normal left ventricular function. Furthermore, the use of ACEIs or ARBs for secondary prevention of AF has been found beneficial only after electrical cardioversion. Additional data are needed to establish the potential clinical role of renin-angiotensin inhibition for prevention of AF.
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Affiliation(s)
- Theodoros Zografos
- Department of Cardiology, Athens Euroclinic, 9 Athanassiadou Street, Athens, Greece
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Yamashita T, Inoue H, Okumura K, Kodama I, Aizawa Y, Atarashi H, Ohe T, Ohtsu H, Kato T, Kamakura S, Kumagai K, Kurachi Y, Koretsune Y, Saikawa T, Sakurai M, Sato T, Sugi K, Nakaya H, Hirai M, Hirayama A, Fukatani M, Mitamura H, Yamazaki T, Watanabe E, Ogawa S, Katoh T, Igawa O, Matsumoto N, Yamashita T, Kaneko Y, Watanabe E, Ogawa S, Osaka T, Fujii E, Niwano S, Yoshioka K, Kato M, Okazaki O, Kusano K, Okuyama Y, Furushima H, Suzuki M, Noda T, Kawara T, Sato T, Kamakura S, Endoh Y, Kumagai K, Hiyoshi Y, Ishiyama T, Ohtsuka T, Matsumoto M, Chishaki A, Shinohara T, Shirayama T, Koretsune Y, Yokoyama E, Ajiki K, Fujio K, Sugi K, Yamakawa T, Yusu S, Inoue H, Kawamura Y, Hayano M, Date T, Mizusawa Y, Kobayashi Y, Satomi K, Imai Y, Atarashi H, Fukunami M, Yokoshiki H, Betsuyaku T, Okumura K, Takeda H, Matsumoto K, Okishige K, Tagawa M, Hirai M, Okazaki H. Randomized trial of angiotensin II-receptor blocker vs. dihydropiridine calcium channel blocker in the treatment of paroxysmal atrial fibrillation with hypertension (J-RHYTHM II Study). Europace 2010; 13:473-9. [DOI: 10.1093/europace/euq439] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Calò L, Martino A, Sciarra L, Ciccaglioni A, De Ruvo E, De Luca L, Sette A, Giunta G, Lioy E, Fedele F. Upstream effect for atrial fibrillation: still a dilemma? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 34:111-28. [PMID: 21029134 DOI: 10.1111/j.1540-8159.2010.02942.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation is the most common arrhythmia in clinical practice. Ion channel blocking agents are often characterized by limited long-term efficacy and several side effects. In addition, ablative invasive procedures are neither easily accessible nor always efficacious. The "upstream therapy," which includes angiotensin-converting enzyme inhibitors, aldosterone receptor antagonists, statins, glucocorticoids, and ω-3 poly-unsaturated fatty acids, targets arrhythmia substrate, influencing atrial structural and electrical remodeling that play an essential role in atrial fibrillation induction and maintenance. The mechanisms involved and the most important clinical evidence regarding the upstream therapy influence on atrial fibrillation are presented in this review. Some open questions are also proposed.
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Affiliation(s)
- Leonardo Calò
- Division of Cardiology, Policlinico Casilino ASL RMB, Rome, Italy
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Schneider MP, Hua TA, Böhm M, Wachtell K, Kjeldsen SE, Schmieder RE. Prevention of atrial fibrillation by Renin-Angiotensin system inhibition a meta-analysis. J Am Coll Cardiol 2010; 55:2299-307. [PMID: 20488299 DOI: 10.1016/j.jacc.2010.01.043] [Citation(s) in RCA: 271] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 12/21/2009] [Accepted: 01/02/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The authors reviewed published clinical trial data on the effects of renin-angiotensin system (RAS) inhibition for the prevention of atrial fibrillation (AF), aiming to define when RAS inhibition is most effective. BACKGROUND Individual studies examining the effects of RAS inhibition on AF prevention have reported controversial results. METHODS All published randomized controlled trials reporting the effects of treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in the primary or secondary prevention of AF were included. RESULTS A total of 23 randomized controlled trials with 87,048 patients were analyzed. In primary prevention, 6 trials in hypertension, 2 trials in myocardial infarction, and 3 trials in heart failure were included (some being post-hoc analyses of randomized controlled trials). In secondary prevention, 8 trials after cardioversion and 4 trials assessing the medical prevention of recurrence were included. Overall, RAS inhibition reduced the odds ratio for AF by 33% (p < 0.00001), but there was substantial heterogeneity among trials. 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% (p = 0.01) and in patients on medical therapy by 63% (p < 0.00001). CONCLUSIONS This analysis supports the concept of RAS inhibition as an emerging treatment for the primary and secondary prevention of AF but acknowledges the fact that some of the primary prevention trials were post-hoc analyses. Further areas of uncertainty include potential differences among specific RAS inhibitors and possible interactions or synergistic effects with antiarrhythmic drugs.
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Affiliation(s)
- Markus P Schneider
- Department of Nephrology and Hypertension, University of Erlangen-Nuremberg, Erlangen, Germany
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Abstract
Failure of current pharmacological therapy for atrial fibrillation in maintaining sinus rhythm may be due to structural atrial remodeling caused by inflammation and fibrosis. Upstream therapy that interferes in the structural remodeling process may be effective in maintaining sinus rhythm. This article reviews upstream therapy in atrial fibrillation. Various prospective and retrospective studies demonstrate that upstream therapy, consisting of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statins, fish oils, glucocorticoids, or moderate physical activity, is associated with a reduced incidence of new-onset atrial fibrillation (i.e., primary prevention) and with a reduced recurrence of atrial fibrillation (i.e., secondary prevention). Larger clinical trials are required to further elucidate the position of upstream therapy in the primary and secondary prevention of atrial fibrillation.
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Affiliation(s)
- Marcelle D Smit
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Current world literature. Curr Opin Endocrinol Diabetes Obes 2009; 16:260-77. [PMID: 19390324 DOI: 10.1097/med.0b013e32832c937e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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