Prospective randomized study comparing amiodarone vs. amiodarone plus losartan vs. amiodarone plus perindopril for the prevention of atrial fibrillation recurrence in patients with lone paroxysmal atrial fibrillation

Yin, Yuehui; Dalal, Darshan; Liu, Zengchang; Wu, Jinjin; Liu, Dong; Lan, Xianbin; Dai, Yu‐Tzu; Li, Su; Ling, Zhiyu; Qiang, Sheng; Luo, Kun; Woo, Kam-Sang; Dong, Jun

doi:10.1093/eurheartj/ehl135

Cited by 102 publications

(90 citation statements)

References 25 publications

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“…(Table 2). In another study, 59 the beneficial effects of RAAS blockade with valsartan or ramipril over amlodipine in hypertensive patients with paroxysmal AF persisted even in the absence of concurrent antiarrhythmic drug. In these studies, there were no significant differences in the BP control between patients assigned to ACEIsor ARBs-based therapy as compared with other antihypertensive agents, mainly calcium channel blockers, suggesting the beneficial effects of ACEIs and ARBs on AF prevention were beyond their BP lowering effect.…”

Section: Raas Activationmentioning

confidence: 97%

Hypertension and atrial fibrillation: epidemiology, pathophysiology and therapeutic implications

Yiu

Siu

et al. 2011

J Hum Hypertens

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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. 1,2 Both hypertension 3 and AF 4 have increased frequency with the ageing population worldwide, and are associated with increased cardiovascular events. They are important risk factors for stroke, heart failure and overall mortality. 5 --7 On the other hand, hypertension is one of the important risk factors for the occurrence of AF, 8 and increased the risk of stroke and cardiovascular mortality in patients with AF.9,10 Compare with other risk factors for AF, hypertension appears to be responsible for more AF than any other risk factor because of its high prevalence. However, the pathophysiological link between AF and hypertension remains unclear. Moreover, it is also unclear whether treatment of hypertension prevents AF or reduces the risk of AF related complications. The purpose of this article is to review the epidemiology, underlying mechanisms and therapeutic implications of AF in hypertensive patients. A systematic literature search for full-text papers in the English language was performed using MEDLINE, Embase and the Cochrane library through to July 2011. In the search phrases used, the following terms were used: 'atrial fibrillation', 'hypertension', 'epidemiology', 'pathophysiology' and 'treatment'. Papers selected and cited in this review were based on the authors' view on the relevance to the manuscript. In addition, abstracts from international cardiovascular meetings were studied to identify unpublished studies.

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Section: Raas Activationmentioning

confidence: 97%

Hypertension and atrial fibrillation: epidemiology, pathophysiology and therapeutic implications

Yiu

Siu

et al. 2011

J Hum Hypertens

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“…7 Previous meta-analyses based on several post hoc analyses of randomized controlled trials have shown that RAS blockers significantly reduced the risk of new-onset AF ranging from 28% to 49%, but this benefit was limited to patients with systolic left ventricular dysfunction or hypertension with LVH. 10,11 For secondary prevention of AF, several relatively small prospective randomized studies [12][13][14] have demonstrated that therapies with ACEI/ARBs conferred an additional benefit on risk of recurrent AF in these patients when coadministered with antiarrhythmic drug therapy, usually amiodarone, compared with antiarrhythmic drug alone. Whether RAS blockade could prevent recurrent AF in paroxysmal AF patients with minor underlying cardiac pathology, who are not undergoing cardioversion and do not receive antiarrhythmic drugs therapy or ACEIs, remains controversial.…”

Section: Main Findingsmentioning

confidence: 99%

Effect of Nifedipine Versus Telmisartan on Prevention of Atrial Fibrillation Recurrence in Hypertensive Patients

Fan

Ling

et al. 2013

Hypertension

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A trial fibrillation (AF) and hypertension are 2 prevalent and often coexisting conditions for which the incidence increases with age, and both are responsible for considerable cardiovascular morbidity and mortality.1 Hypertension is the most prevalent and independent risk factor of developing AF. 2,3 Previous studies demonstrated that hypertension was associated with left ventricular hypertrophy (LVH), impaired ventricular filling, left atrial (LA) structural changes, and slowing of atrial conduction velocity. 4 Meanwhile, antihypertensive treatment could reduce the risk of AF by reversing structural cardiac damage caused by hypertension. 5,6 All antihypertensive drugs reduce left ventricular and LA filling pressures and wall stress. However, preventing structural changes may be an effect specific to angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs).Recently, angiotensin II has been recognized as a key factor in atrial structural and electric remodeling associated with AF.7 There are many potential mechanisms by which inhibition of the renin-angiotensin system (RAS) may reduce AF. Besides reducing the blood pressure (BP), per se, RAS blockers may prevent LA dilatation, atrial fibrosis, dysfunction, and conduction velocity slowing, and thereby have a greater effectiveness in patients with heart failure and LVH as seen in the meta-analysis by Schneider et al. 8 Furthermore, previous studies suggested that the ARB was more effective than the dihydropyridine calcium channel blocker in ameliorating atrial structural remodeling.9 Hence, RAS blockers might have more benefit beyond BP control than the dihydropyridine calcium channel blocker for hypertensive patients with paroxysmal AF.The present study was aimed to evaluate whether telmisartan-based treatment was superior to nifedipine-based treatment in hypertensive patients with paroxysmal AF after intensive BP control. Patients and Methods Study PopulationThe Nifedipine versus Telmisartan on Prevention of AF recurrence in hypertensive patients with AF trial (NTP-AF study, NCT01435161) was a prospective, randomized, open-label, parallel trial and was conducted from April 2006 to December 2011. All hypertensive patients with paroxysmal AF who were referred to the second affiliated Hospital of Chongqing Medical University were invited to participate in this study. All patients underwent history acquisition, physical examination, standard 12-lead ECG, 24-hour Holter monitoring, echocardiogram, chest X-ray, and thyroid and renal function tests before Abstract-It is controversial whether angiotensin II receptor blockers provide better protection than calcium antagonists against atrial fibrillation (AF) recurrence in hypertensive patients. This study was designed to compare the effect of nifedipine-and telmisartan-based antihypertensive treatments for preventing AF recurrence in hypertensive patients with paroxysmal AF. A total of 149 hypertensive patients with paroxysmal AF were randomized to nifedipine-or telmisartanbased antihyper...

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“…The group on enalapril showed a higher probability of remaining in sinus rhythm at four weeks (84.3% vs 61.3%, P = 0.002) and at a median followup period of 270 days (74.3% vs 57.3%, P = 0.021). Yin et al [2006] compared the efficacy, in the long term, of amiodarona at a low dose (200 mg) alone, or combined with losartan or perindopril, in the prevention of the recurrence of paroxysms in isolated AF in 177 patients after 24 months of follow-up. AF recurrence was found to be 41, 19, and 24%, respectively (P = 0.02).…”

Section: Therapeutic Advances In Cardiovascular Diseasementioning

confidence: 99%

Review: Atrial fibrillation and renin-angiotensin system

Serra

Boccadoro

2008

Therapeutic Advances in Cardiovascular Disease

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Atrial Fibrillation (AF) is one of the most frequent arrhythmias, especially in elderly patients. Cardiac overload increases the incidence of AF. Clinical presentation of atrial fibrillation can occur as nonsustained paroxysms, persistent episodes and in chronic-permanent form. The physio-pathological mechanisms are:• Circuit of multiple and anarchic re-entries • Atrial fibrillatory conduction • Re-entry circuit with fibrillatory conduction. Remodeling (electrical or structural) facilitates the appearance and persistence of AF: Neurovegetative changes and cytosolic Ca overload facilitate AF. Interstitial atrial fibrosis, in which Renin-Angiotensin System (RAS) hyperactivity is a main aspect of remodeling. There is clinical evidence that supports the antiatrial fibrillatory actions of RAS blockade. Potential mechanisms are: (a) direct modulation of ionic channels, (b) hemodynamic improvement, (c) reduction of atrial stretching, (d) antifibrotic effects. There is less clinical evidence with antialdosterone drugs, but theoretically these might also be useful. Keywords: atrial fibrillation, remodeling, renin-angiotensin systemAtrial fibrillation, pathophysiology, remodeling. Atrial fibrillation (AF) is one of the most frequent arrhythmias in adulthood, with its incidence increasing with age. The situations and pathologies that lead to hemodynamic or pressure overload are associated to AF. This can be present as nonsustained paroxysms, persistent episodes (reverted to Sinus Rhythm by medical treatments) and as chronic-permanent AF. It is referred to as 'isolated' when there is no structural cardiopathy or other morbid entities that can explain it. Three mechanisms have been described to explain its physiopathogenia [Nattel and Ehrlich, 2004]: a. Multiple, coexistent, anarchic re-entry circuits. AF settles down if the conditions are appropriate for them to appear and persist over time. These alterations involve refractoriness (reduction), velocity of conduction (delay), and an increase in heterogeneity of both properties [Moe and Abildskov, 1995;Cosio, 1994;Cosio and Arribas, 1989;Allessie, et al. 1985;Moe, 1962]. The quantity of atrial 'mass' (atrial volume) is also a determining factor. For hearts with big atria, AF is more frequent and lasting [Henry et al. 1976]. The persistence of the fibrillatory state depends on the number of the aforementioned re-entries circuits that are simultaneously present, at any determined moment. Few coexistent re-entries diminish the possibility of persistence.b. Rapid and continued ectopic activity, with 'fibrillatory conduction' in auricles, due to its impossibility to respond in an organized form.c. Only one circuit of re-entry with 'fibrillatory conduction,' with this 'fibrillatory conduction' also depending on the heterogeneity of refractoriness and atrial conductivity.An interrelationship may exist between these three mechanisms.An episode of AF needs a 'trigger' (premature beats, tachycardia) to initiate it, by interaction with 'modulators' (neurovegetative system, br...

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Prospective randomized study comparing amiodarone vs. amiodarone plus losartan vs. amiodarone plus perindopril for the prevention of atrial fibrillation recurrence in patients with lone paroxysmal atrial fibrillation

Cited by 102 publications

References 25 publications

Hypertension and atrial fibrillation: epidemiology, pathophysiology and therapeutic implications

Hypertension and atrial fibrillation: epidemiology, pathophysiology and therapeutic implications

Effect of Nifedipine Versus Telmisartan on Prevention of Atrial Fibrillation Recurrence in Hypertensive Patients

Review: Atrial fibrillation and renin-angiotensin system

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