Losartan and Prevention of Atrial Fibrillation Recurrence in Hypertensive Patients

Abstract

The aim of the study was to evaluate the effect of losartan as compared with amlodipine, both associated with amiodarone, in preventing the recurrence of atrial fibrillation (AF) in hypertensive patients with a history of recent paroxysmal atrial fibrillation. Two hundred and fifty mild hypertensive (SBP > 140 mm Hg and/or DBP > 90 < 100 mm Hg) outpatients in sinus rhythm but with at least two ECG-documented episodes of symptomatic atrial fibrillation in the previous 6 months and in treatment with amiodarone were randomized to losartan or amlodipine and were followed up for 1 year. Clinic blood pressure (BP) and a 24-hour ECG was evaluated every month; the patients were asked to report any episode of symptomatic atrial fibrillation and to perform an ECG as early as possible. Two hundred and thirteen patients completed the study, 107 in the losartan group and 106 in the amlodipine group. After 12 months the SBP/DBP mean values were significantly reduced by both losartan (from 151.4/95.6 to 135.5/83.7 mm Hg, P < 0.001 versus baseline) and amlodipine (from 152.3/96.5 to 135.2/83.4 mm Hg, P < 0.001 versus baseline), with no difference between the two treatments. At least one ECG-documented episode of atrial fibrillation was reported in 13% of the patients treated with losartan and in 39% of the patients treated with amlodipine. The use of losartan in combination with amiodarone seems more effective than amlodipine/amiodarone combination in preventing new episodes of atrial fibrillation in hypertensive patients with recurrent atrial fibrillation. This might be related to possible favorable impact of angiotensin II receptor blockers (ARB) on the atrial electrical and structural remodeling in this type of patients.

Hypertension and cardiac arrhythmias: a review of the epidemiology, pathophysiology and clinical implications

“…71 In patients with concomitant hypertension and AF, ARB-based therapy (losartan) in combination with amiodarone was also more effective than CCB-based therapy (amlodipine) in preventing the recurrence of AF. 74 Nevertheless, meta-analysis of three major clinical trials (Captopril Prevention Project (CAPP), Swedish Trial in Old Patients with Hypertension-2 (STOP-H-2) and LIFE) including 12 114 patients with hypertension have failed to show a consistent reduction in AF with ACEI and ARB. 75 In addition to the blockade of RAAS with specific agents, both the blood pressurelowering effect and LVH regression of different antihypertensive agents make an important contribution to the prevention of AF.…”

The left atrium, atrial fibrillation, and the risk of stroke in hypertensive patients with left ventricular hypertrophy

“…Evidence suggests that agents that inhibit the RAAS may have primary and secondary preventative properties when administered alone or with agents traditionally administered for prevention of atrial fibrillation, such as amiodarone [Fogari et al 2006;Wachtell et al 2006b]. Furthermore, the ONgoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET) results were recently published [ONTARGET Investigators.…”

“…More direct support for benefit of RAAS blockade is provided by a recent report from the Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) study, indicating that patients randomized to valsartanbased versus amlodipine-based therapy had a 16% lower incidence of new atrial fibrillation, although ARB-based treatment was associated with less blood pressure reduction than achieved by alternative calcium-blocker-based treatment [Schmieder et al 2008]. In a smaller of study of patients with previous paroxysmal atrial fibrillation, losartan versus amlodipine treatment added to amiodarone antiarrhythmic therapy reduced the recurrence rate of this arrhythmia by 2/3 despite similar blood pressure lowering [Fogari et al 2006]. …”

“…However, the atrial fibrillation guidelines also state that additional randomized trials will be required before drugs modulating the RAAS can be routinely recommended. Given this, and although no ACE inhibitor or ARB is indicated for primary or secondary prevention of atrial fibrillation in its product labeling at this time, use Review of these agents for conditions for which they are indicated (e.g., hypertension, heart failure, and type 2 diabetes and nephropathy) may provide the additional benefit of reducing the risk for atrial fibrillation [Fogari et al 2006]. In keeping with this concept, the latest European guidelines on hypertension have now embraced atrial fibrillation as a risk factor and in a position statement recommended treatment with ACE inhibitor or ARB for recurrent atrial fibrillation in the setting of hypertension [Mancia et al 2007].…”

Randomized Study of Angiotensin II Type 1 Receptor Blocker vs Dihydropiridine Calcium Antagonist for the Treatment of Paroxysmal Atrial Fibrillation in Patients With Hypertension The J-RHYTHM II Study Design for the Investigation of Upstream Therapy for Atrial Fibrillation

“…In actual fact, angiotensin II type 1 receptor blockers (ARB) have been recently reported to suppress AF recurrence in both persistent and PAF in selected patients. [13][14][15][16][17] These studies, however, did not assess the existence of asymptomatic AF, an important factor that could alter the interpretation of many previous clinical studies. 18 The Japanese Rhythm Management Trial II for Atrial Fibrillation (J-RHYTHM II study) has been designed to be a prospective, randomized, and multicenter study to test the Background Mega trials of rhythm vs rate control could not demonstrate the usefulness of available antiarrhythmic drugs, so a more effective and safer therapy for atrial fibrillation (AF) is now required.…”