Meta-analysis of renin angiotensin aldosterone modulators mitigating Atrial Fibrillation risk in hypertensive patients

INTRODUCTION

Hypertension is associated with left ventricular hypertrophy/enlargement/fibrosis and atrial ectopic rhythm, leading to an increased risk of Atrial Fibrillation (AF). We aimed to stratify the effect of Angiotensin Converting Enzyme Inhibitors (ACEi) and Angiotensin Receptor Blockers (ARB) on the risk of AF.

METHODS

PubMed, Scopus, and Google Scholar databases were screened, and cross-citation was conducted for studies reporting AF in hypertensive patients on ACEi and ARB. Of 145 studies found till May 2023, 19 were included in this study. Binary random-effects models estimated the pooled odds ratios, I2 statistics assessed heterogeneity and sensitivity analysis was assessed using the leave-one-out method.

RESULTS

153,559 hypertensive patients met the inclusion criteria. For incidental AF, ACEi and ARB showed a significant decrease in both unadjusted (OR 0.75, 95% CI [0.66-0.85], I² = 20.79%, p=0.29) and adjusted risks (OR 0.76, 95% CI [0.62-0.93], I² = 88.41%, p<0.01). In recurrent AF, the unadjusted analysis showed no significant effect (OR 0.89, 95% CI [0.55-1.42], I² = 78.44%, p<0.01), while the adjusted analysis indicated a reduced risk (OR 0.62, 95% CI [0.50-0.76], I² = 65.71%, p<0.01). Leave-one-out sensitivity analysis confirmed these results.

CONCLUSIONS

ACEi and ARB considerably decrease the risk of incidental and recurrent AF in hypertensive patients, emphasizing the importance of treating clinical hypertension with these drugs.

Hypertension and atrial fibrillation

Hypertension is the most prevalent cardiovascular risk factor underlying atrial fibrillation and is present in up to 40% of patients with atrial fibrillation. Furthermore, attributable risk studies have shown that a history of hypertension contributes to up to 24% of incident atrial fibrillation. New data suggest that even early forms of hypertension (prehypertension and aortic stiffness) are associated with an increased risk of atrial fibrillation development. Hypertension and prehypertension are therefore critical mediators for the development of atrial fibrillation. Mechanisms for the association between hypertension and atrial fibrillation include diffuse electro-structural changes to the left atrium, driven by the haemodynamic and neurohormonal influences of hypertension and other, frequently coexisting, cardiovascular risk factors. Management of hypertension in atrial fibrillation should focus not only on blood pressure reduction but also on a comprehensive risk factor modification strategy. Such strategies have been shown to be associated with significant improvements in atrial fibrillation symptom burden as well as improved arrhythmia-free survival and reversal of the progression of atrial fibrillation. These strategies should focus on dietary modifications as well as prescribed exercise programmes involving a multidisciplinary team and patient-centred atrial fibrillation care. Risk factor management, supplemented by antihypertensive medications as needed, provides the optimum strategy for improving outcomes and even reversing the natural progression of atrial fibrillation in patients with hypertension.

Effect of Perindopril on Atrial Fibrillation Recurrence and Burden: Results of the Canadian Trial of Atrial Fibrillation (CTAF)-2

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.

Angiotensin II and angiotensin 1-7: which is their role in atrial fibrillation?

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.

Effects of RAAS Blockers on Atrial Fibrillation Prophylaxis

Background:

Impact of atrial fibrillation on clinical outcomes is well recognized, and application of renin–angiotensin–aldosterone system (RAAS) blockers for the prevention of atrial fibrillation (AF) is a theoretically appealing concept. However, clinical trials have yielded inconsistent results.

Methods:

A pooled study of 26 randomized controlled trials (RCTs) assessing the efficacy of RAAS blockers on AF prophylaxis was performed.

Results:

A total of 28 reports from 26 randomized controlled trials enrolled 165 387 patients, with an overall 24% reduction in the incidence of AF (odds ratio [OR]: 0.76, 95% confidence interval [CI]: 0.68-0.85], P = .000). Forty-nine percent reduction in the incidence of AF (OR: 0.51, 95% CI: 0.30-0.85, P = .010) in systolic heart failure was observed, whereas no significant effect was observed in patients with diastolic heart failure, postmyocardial infarction, and high cardiovascular disease risk. There was a 19% (OR: 0.81, 95% CI: 0.67-1.00, P = .037) reduction in new-onset and 54% (OR: 0.46, 95% CI: 0.33-0.62, P = .000) reduction in recurrent AF in hypertensive patients with 39% (OR: 0.61, 95% CI: 0.44-0.84, P = .003) risk reduction against calcium blockers and 41% (OR: 0.59, 95% CI: 0.44-0.80, P = .001) risk reduction against β blockers. Angiotensin-receptor blocker appeared marginally superior to angiotensin-converting enzyme inhibitor in primary and secondary prevention.

Conclusion:

This study suggests that RAAS blockade effectively suppresses AF in systolic heart failure, and hypertensives derive greater benefit against new-onset and recurrent AF compared to β blockers, calcium channel blockers, and diuretics.

Prevention of atrial fibrillation with renin-angiotensin system inhibitors on essential hypertensive patients: a meta-analysis of randomized controlled trials

We aimed to investigate the effectiveness and safety of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) on preventing atrial fibrillation in essential hypertensive patients. Systematic literature retrieval was carried out to obtain randomized controlled trials on the effects of ACEI/ARBs on essential hypertensive patients before December, 2013. Data extraction and quality evaluation were performed. Meta-analysis was performed by Review Manager 5.2.3. Ten high quality studies (11 articles) with a total of 42,892 patients (20,491 patients in the ACEI/ARBs group and 22,401 patients in the β-blocker or the calcium antagonist group) met the inclusion criteria and were included in the meta-analysis. The results showed that ACEI/ARBs reduced the incidence of atrial fibrillation (AF) recurrence compared to calcium antagonists (RR = 0.48; 95%CI, 0.40-0.58; P<0.00001) or β-blockers (RR = 0.39; 95%CI, 0.20-0.74; P = 0.005) in long-term follow-up, respectively. Furthermore, ACEI/ARBs reduced the incidence of congestive heart failure (RR = 0.86; 95%CI, 0.77-0.96; P = 0.007). However, no significant effects were observed on the incidence of new AF, cardiac death, myocardial infarction, and stroke. Our results suggest that ACEI/ARBs may reduce the incidence of AF recurrence and congestive heart failure, with fewer serious adverse effects.

Effects of candesartan, an angiotensin II receptor type I blocker, on atrial remodeling in spontaneously hypertensive rats

Hypertension‐induced structural remodeling of the left atrium (LA) has been suggested to involve the renin–angiotensin system. This study investigated whether treatment with an angiotensin receptor blocker, candesartan, regresses atrial remodeling in spontaneously hypertensive rats (SHR). Effects of treatment with candesartan were compared to treatment with a nonspecific vasodilatator, hydralazine. Thirty to 32‐week‐old adult male SHR were either untreated (n = 15) or received one of either candesartan cilexetil (n = 9; 3 mg/kg/day) or hydralazine (n = 10; 14 mg/kg/day) via their drinking water for 14 weeks prior to experiments. Untreated age‐ and sex‐matched Wistar‐Kyoto rats (WKY; n = 13) represented a normotensive control group. Untreated SHR were hypertensive, with left ventricular hypertrophy (LVH) compared to WKY, but there were no differences in systolic pressures in excised, perfused hearts. LA from SHR were hypertrophied and showed increased fibrosis compared to those from WKY, but there was no change in connexin‐43 expression or phosphorylation. Treatment with candesartan reduced systolic tail artery pressures of conscious SHR below those of normotensive WKY and caused regression of both LVH and LA hypertrophy. Although hydralazine reduced SHR arterial pressures to those of WKY and led to regression of LA hypertrophy, it had no significant effect on LVH. Notably, LA fibrosis was unaffected by treatment with either agent. These data show that candesartan, at a dose sufficient to reduce blood pressure and LVH, did not cause regression of LA fibrosis in hypertensive rats. On the other hand, the data also suggest that normalization of arterial pressure can lead to the regression of LA hypertrophy.

Structural remodeling of the atria, involving atria enlargement and fibrosis, in hypertension increases the risk of atrial fibrillation (AF). Treatment of spontaneously hypertensive rats with the angiotensin receptor blocker, candesartan, reduced arterial pressure and myocardial hypertrophy to the level of normotensive rats but had no effect on atrial fibrosis. The resistance of hypertension‐associated atrial fibrosis to the AT1 receptor antagonist may provide insight into the basis to the ineffectiveness of drugs targeting the renin–angiotensin system in reducing incidence of AF in hypertensive patients.

Renin-angiotensin system inhibitors prevent the recurrence of atrial fibrillation: a meta-analysis of randomized controlled trials

OBJECTIVE

This study was designed to assess whether angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) could prevent the recurrence of atrial fibrillation (AF).

METHODS

A systemic literature search of PubMed, EMBASE, and Cochrane Controlled Trials Register till 2012 was performed to identify randomized controlled trials involving the prevention of recurrence of AF with renin-angiotensin system blockade therapy. Subgroup analysis and meta-regression were performed. Publication bias was checked through funnel plot and Egger's test.

RESULTS

Twenty-one randomized controlled trials including 13,184 patients with AF were identified. Overall, the recurrence of AF was significantly reduced in patients using ACEI/ARBs [odds ratio (OR), 0.43; 95% confidence interval (CI), 0.32-0.56; P < 0.00001], especially both in irbesartan subgroup (OR, 0.38; 95% CI, 0.21-0.68; P = 0.001) and in patients receiving antiarrhythmic drug (AAD) (OR, 0.37; 95% CI, 0.29-0.48; P < 0.00001), and there was no significant difference between ACEIs and ARBs (ACEIs: OR, 0.42; 95% CI, 0.31-0.57 and ARBs: OR, 0.42; 95% CI, 0.31-0.57). Moreover, it was found that the benefits of ACEI/ARBs revealed positive correlation to systolic blood pressure (regression coefficient: -0.0700257, P = 0.000) in no-AAD users.

CONCLUSIONS

ACEI/ARBs are effective on the secondary prevention of AF, especially in patients receiving AAD and suffering from hypertension.

Routine versus aggressive upstream rhythm control for prevention of early atrial fibrillation in heart failure: background, aims and design of the RACE 3 study

Background

Rhythm control for atrial fibrillation (AF) is cumbersome because of its progressive nature caused by structural remodelling. Upstream therapy refers to therapeutic interventions aiming to modify the atrial substrate, leading to prevention of AF.

Objective

The Routine versus Aggressive upstream rhythm Control for prevention of Early AF in heart failure (RACE 3) study hypothesises that aggressive upstream rhythm control increases persistence of sinus rhythm compared with conventional rhythm control in patients with early AF and mild-to-moderate early systolic or diastolic heart failure undergoing electrical cardioversion.

Design

RACE 3 is a prospective, randomised, open, multinational, multicenter trial. Upstream rhythm control consists of angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers, mineralocorticoid receptor antagonists, statins, cardiac rehabilitation therapy, and intensive counselling on dietary restrictions, exercise maintenance, and drug adherence. Conventional rhythm control consists of routine rhythm control therapy without cardiac rehabilitation therapy and intensive counselling. In both arms, every effort is made to keep patients in the rhythm control strategy, and ion channel antiarrhythmic drugs or pulmonary vein ablation may be instituted if AF relapses. Total inclusion will be 250 patients. If upstream therapy proves to be effective in improving maintenance of sinus rhythm, it could become a new approach to rhythm control supporting conventional pharmacological and non-pharmacological rhythm control.

An update on telmisartan/hydrochlorothiazide combinations for the management of hypertensive patients with additional cardiovascular risk factors

International hypertension guidelines endorse the use of combination therapy to achieve blood pressure control in the majority of patients. Angiotensin AT1 receptor blockers, in combination with diuretics, are among the preferred combinations, with telmisartan plus hydrochlorothiazide (HCTZ) being an effective and well-tolerated combination. This article provides an up-to-date review of the existing data on telmisartan/HCTZ combination for the management of hypertension in patients with additional cardiovascular risk factors, including reports emerging from a number of recent clinical trials and secondary analyses of older trials. The accumulated evidence from clinical trials demonstrates that telmisartan/HCTZ combinations are effective and well tolerated in patients with mild-to-severe hypertension, including subgroups of patients with cardiovascular risk factors such as advanced age, obesity, chronic kidney disease, diabetes mellitus and treatment-resistant hypertension.