Department of Nephrology and Hypertension, University of Erlangen-Nuremberg, Erlangen, Germany.
J Am Coll Cardiol. 2010 May 25;55(21):2299-307. doi: 10.1016/j.jacc.2010.01.043.
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.
Individual studies examining the effects of RAS inhibition on AF prevention have reported controversial results.
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.
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).
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.
作者回顾了已发表的关于肾素-血管紧张素系统（RAS）抑制预防心房颤动（AF）的临床试验数据，旨在确定 RAS 抑制何时最有效。
个别研究 RAS 抑制对 AF 预防作用的研究结果存在争议。
纳入所有发表的关于血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂在 AF 的一级或二级预防中治疗效果的随机对照试验。
共分析了 23 项随机对照试验，共 87048 例患者。一级预防中，纳入了 6 项高血压试验、2 项心肌梗死试验和 3 项心力衰竭试验（部分为随机对照试验的事后分析）。二级预防中，纳入了 8 项电复律后和 4 项评估复发性预防的试验。总的来说，RAS 抑制使 AF 的优势比降低了 33%（p<0.00001），但试验之间存在很大的异质性。在一级预防中，RAS 抑制对心力衰竭和高血压伴左心室肥厚患者有效，但对心肌梗死后患者总体无效。在二级预防中，RAS 抑制通常与抗心律失常药物联合使用，包括胺碘酮，进一步使电复律后 AF 复发的优势比降低了 45%（p=0.01），在接受药物治疗的患者中降低了 63%（p<0.00001）。
这项分析支持 RAS 抑制作为 AF 一级和二级预防的新兴治疗方法的概念，但也承认一些一级预防试验是事后分析。进一步的不确定性包括特定 RAS 抑制剂之间的潜在差异，以及与抗心律失常药物的可能相互作用或协同作用。
