The Effects of Rate and Rhythm Control on Blood Pressure and Antihypertensive Drug Usage in Patients with Atrial Fibrillation and Hypertension Enrolled in the AFFIRM Trial

Atrial Fibrillation Detection and Management in Hypertension

Hypertension is prevalent in >70% of atrial fibrillation patients. In turn, hypertensive patients have up to 73% greater likelihood of atrial fibrillation. Current guidelines recommend that a systematic atrial fibrillation screening may be justified in all patients aged ≥65 years with at least 1 cardiovascular disease, including hypertension. Although most blood pressure monitors include algorithms to detect atrial fibrillation with a high sensitivity of 96 [92-98]% and specificity of 94 [91-96]%, an electrocardiography confirmation is necessary to establish a diagnosis of atrial fibrillation. Early detection and diagnosis of atrial fibrillation is important to allow initiation of atrial fibrillation management. In the Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4), hypertension was present in 88% of participants, and early rhythm control therapy lowered the risk of adverse cardiovascular outcomes in patients with early atrial fibrillation aged >75 or with CHA₂DS₂-VASc score ≥2 (Congestive heart failure, Hypertension, Age ≥75 (doubled), Diabetes, Stroke (doubled), Vascular disease, Age 65-74, Sex category [female]) and cardiovascular condition. Strategies for early atrial fibrillation detection should always be linked to a comprehensive atrial fibrillation work-up infrastructure organized within an integrated ABC pathway (Anticoagulation/Avoid stroke; Better symptom control; Cardiovascular and Comorbidity optimization). For secondary prophylaxis, blood pressure control should be embedded in a combined risk factor management program. In hypertensive patients where no atrial fibrillation is detected, intensive blood pressure lowering therapy for primary prophylaxis should be initiated to reduce the risk of developing atrial fibrillation and other cardiovascular complications in the future. The aim of the article is to review the current literature on atrial fibrillation detection and management in hypertensive patients.

Left Atrial Size May Predict Blood Pressure Improvement After Ganglionated Plexi Ablation in Addition to Pulmonary Vein Isolation

Background

Hypertension (HTN) and atrial fibrillation (AF) commonly co-exist. An improvement in control of HTN in a subset of patients undergoing AF ablation was previously demonstrated by our group. In the present study, we aimed to assess whether left atrial (LA) size based on transthoracic echocardiography may predict the patients who demonstratebetter HTN improvement after ganglionated plexus ablation (GPA) in addition to pulmonary vein isolation (PVI).

Methods

This was a retrospective chart review of patients with AF and HTN who underwent GPA+PVI. Patients were divided into 2 groupsbased on LA size: Patients with normal LA size and patients with LA enlargement. Systolic blood pressure (SBP) levelswere compared at baseline, and 3, 6, and 12 months post-ablation. The primary endpoints of the study weremean systolic blood pressure change compared between groups from baseline to 12-months, as well as the absolute difference in systolic blood pressure at 12 months follow-up.Medical therapy for HTN was also assessed before the procedure, and at 12 months post-procedure.

Results

53 patients (37 with LA enlargement, 16 with normal LA size) met inclusion criteria. At 12 months follow-up, SBP was 136.46 ± 22.38 mmHg in patients with LA enlargementand 118.25 ± 9.81 mmHg in patients with normal LA size (estimated difference of 19.04 ± 6.98 mmHg, p = 0.01). Patients with normal LA size were on significantly fewer anti-hypertensive agents at 12 months (2.33 ± 1.49 vs. 1.44 ± 1.21, p < 0.05).

Conclusions

In patients undergoing PVI+GP ablation, normal LA size may predict HTN improvement at 12 months post-procedure. Normal LA size may identify hypertensive AF patients for whom autonomic modulation could be an effective therapy.

A trial of three non-invasive blood pressure monitors compared with invasive blood pressure assessment in atrial fibrillation and sinus rhythm

OBJECTIVE

To investigate the accuracy of three non-invasive blood pressure (BP) devices in atrial fibrillation (AF) compared with invasive arterial BP.

METHODS

One hundred patients aged 45-90 years, 63% male (50 in AF and 50 age matched controls in sinus rhythm [SR]) were identified with arterial lines measuring beat-to-beat BP fluctuation. Non-invasive BP measurements utilising the manual sphygmomanometer (MS), PulseCor R6.5 (PC) and automated sphygmomanometer (AS) were taken simultaneously with invasive BP in a randomised sequence. This was repeated three times in each patient.

RESULTS

In SR differences in systolic BP (SBP) for MS, AS and PC were -0.34 mm Hg (95% CI -2.31 to 1.63; P = .733), -3.80 mm Hg (95% CI -5.73 to -1.87; P = .0001) and -3.90 mm Hg (95% CI -5.90 to -1.90; P = .0001) and for diastolic BP (DBP) were 6.02 mm Hg (95% CI 4.39-7.64; P < .0001), 8.95 mm Hg (95% CI 7.36-10.55; P < .0001) and 7.54 mm Hg (95% CI 5.89-9.18; P < .0001), respectively. In AF mean differences in SBP for MS, AS and PC were -7.33 mm Hg (95% CI -9.11 to -5.55; P < .0001), -5.29 mm Hg (95% CI -7.08 to -3.50; P < .0001) and -5.75 mm Hg (95% CI -7.54 to -3.96; P < .0001) respectively and for DBP were 5.28 mm Hg (95% CI 4.03-6.54; P < .0001), 6.26 mm Hg (95% CI 5.00-7.52; P < .0001) and 6.89 mm Hg (95% CI 5.64-8.15; P < .0001) respectively.

CONCLUSIONS

The MS is accurate in SR because of direct assessment of Korotkoff sounds. Non-invasive BP assessment in AF is significantly less accurate. These findings have important prognostic and therapeutic implications.

[Relationship between antihypertensive drug use and development of atrial fibrillation in hypertensive patients in a Primary Care center]

INTRODUCTION

Although antihypertensive treatment can reduce the risk of cardiovascular morbimortality, studies aimed at evaluating the association between antihypertensive drug use and incidence of atrial fibrillation (AF) yield mixed results. This study aimed to determine the possible relationship between antihypertensive drug use and development of AF.

MATERIAL AND METHODS

Case control study.

CASES

Hypertensive patients with AF diagnosed at least one year after the start of drug treatment for hypertension.

CONTROLS

Hypertensive patients without AF with pharmacological antihypertensive treatment for at least one year, matching by sex, age and duration of antihypertensive therapy at diagnosis of AF cases. The study included 136 cases and 132 controls.

VARIABLES

AF, antihypertensive drugs, control of hypertension, duration of treatment with antihypertensive drugs, number of antihypertensive drugs.

ANALYSIS

Crude OR were calculated, with logistic regression being used to calculate the adjusted odds ratios.

RESULTS

Overall, diuretics was close to statistical significance: OR 0.616 (95% CI 0.365 to 1.040), as a protective factor for development of AF. Calcium channel blockers behaved as a protective factor against development of AF at 75 years or older (OR 0.366; 95% CI 0.173 to 0.772), and within this age in women (OR 0.343; 95% CI 0.145-0.811).

CONCLUSIONS

Calcium channel blockers in the group of 75 years or more, especially in women, worked statistically significant as a drug protecting against the appearance of AF. Diuretics may have a protective role in AF incidence in all hypertensive patients.

The effects of radio-frequency ablation on blood pressure control in patients with atrial fibrillation and hypertension

PURPOSE

The effects of radio-frequency ablation (RFA) on blood pressure (BP) regulation in patients with atrial fibrillation (AF) and hypertension remain unknown. We hypothesized that patients with successful ablation had a lower BP and/or lesser utilization of antihypertensive drug therapy during follow-up when compared to patients with failed ablation.

METHODS AND RESULTS

This was a retrospective evaluation of patients with AF and hypertension treated with ablation at the University of Utah between July 2006 and June 2010. BP and use of antihypertensive medications were assessed at baseline and 1 year follow-up. A total of 167 patients were identified. Eight patients were excluded due to the need for AAD therapy beyond the blanking period thus leaving 80 patients in the success group and 79 patients in the failure group. The mean BP and HR at baseline were not significant between the groups. In the success group, the mean systolic BP decreased from a baseline value of 129 ± 17 to 125 ± 14 mmHg at 1 year (p = 0.075). In contrast, in the failure group, the mean systolic BP increased from a baseline value of 124 ± 16 to 127 ± 14 mmHg at 1 year (p = 0.176). Between-group comparison revealed a p value of 0.026. Minimal changes in diastolic BP were noted in both groups. No significant changes in antihypertensive therapy were noted.

CONCLUSION

We have shown that successful catheter ablation in patients with AF and hypertension is associated with a decrease in systolic BP when compared to an increase in patients with failed ablation. Our findings suggest that restoring sinus rhythm could have an antihypertensive effect in patients with AF and hypertension.

The role of the renin-angiotensin system blocking in the management of atrial fibrillation

OBJECTIVE

To review current available evidence for the role of renin-angiotensin system blockade in the management of atrial fibrillation.

METHOD

We conducted a PubMed and Medline literature search (January 1980 through July 2011) to identify all clinical trials published in English concerning the use of angiotensin converting enzyme inhibitors or angiotensin II receptor blockers for primary and secondary prevention of atrial fibrillation. We also discussed renin-angiotensin system and its effects on cellular electrophysiology.

CONCLUSION

The evidence from the current studies discussed does not provide a firm definitive indication for the use of angiotensin converting enzyme inhibitors or angiotensin II receptor blockers in the primary or secondary prevention of atrial fibrillation. Nevertheless, modest benefits were observed in patients with left ventricular dysfunction. In view of the possible benefits and the low incidence of side-effects with angiotensin converting enzyme inhibitors and angiotensin II receptor blockers, they can be given to patients with recurrent AF, specifically those with hypertension, heart failure and diabetes mellitus.