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BACKGROUND

Randomised evidence on the efficacy of blood pressure (BP)-lowering treatment to reduce cardiovascular risk in patients with atrial fibrillation (AF) is limited. Therefore, this study aimed to compare the effects of BP-lowering drugs in patients with and without AF at baseline.

METHODS AND FINDINGS

The study was based on the resource provided by the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC), in which individual participant data (IPD) were extracted from trials with over 1,000 patient-years of follow-up in each arm, and that had randomly assigned patients to different classes of BP-lowering drugs, BP-lowering drugs versus placebo, or more versus less intensive BP-lowering regimens. For this study, only trials that had collected information on AF status at baseline were included. The effects of BP-lowering treatment on a composite endpoint of major cardiovascular events (stroke, ischaemic heart disease or heart failure) according to AF status at baseline were estimated using fixed-effect one-stage IPD meta-analyses based on Cox proportional hazards models stratified by trial. Furthermore, to assess whether the associations between the intensity of BP reduction and cardiovascular outcomes are similar in those with and without AF at baseline, we used a meta-regression. From the full BPLTTC database, 28 trials (145,653 participants) were excluded because AF status at baseline was uncertain or unavailable. A total of 22 trials were included with 188,570 patients, of whom 13,266 (7%) had AF at baseline. Risk of bias assessment showed that 20 trials were at low risk of bias and 2 trials at moderate risk. Meta-regression showed that relative risk reductions were proportional to trial-level intensity of BP lowering in patients with and without AF at baseline. Over 4.5 years of median follow-up, a 5-mm Hg systolic BP (SBP) reduction lowered the risk of major cardiovascular events both in patients with AF (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.83 to 1.00) and in patients without AF at baseline (HR 0.91, 95% CI 0.88 to 0.93), with no difference between subgroups. There was no evidence for heterogeneity of treatment effects by baseline SBP or drug class in patients with AF at baseline. The findings of this study need to be interpreted in light of its potential limitations, such as the limited number of trials, limitation in ascertaining AF cases due to the nature of the arrhythmia and measuring BP in patients with AF.

CONCLUSIONS

In this meta-analysis, we found that BP-lowering treatment reduces the risk of major cardiovascular events similarly in individuals with and without AF. Pharmacological BP lowering for prevention of cardiovascular events should be recommended in patients with AF.

背景

随机对照试验结果显示，降压治疗在降低房颤（AF）患者心血管风险方面的疗效有限。因此，本研究旨在比较基线时伴有和不伴有 AF 的患者接受降压药物治疗的效果。

方法

本研究基于血压降压治疗试验者协作组（BPLTTC）提供的资源，从每个臂随访超过 1000 患者-年的试验中提取个体参与者数据（IPD），并随机分配患者接受不同类别的降压药物、降压药物与安慰剂或更强化与非强化降压方案治疗。本研究仅纳入了基线时收集 AF 状态信息的试验。采用基于 Cox 比例风险模型的固定效应一阶 IPD 荟萃分析，根据试验分层，根据基线时的 AF 状态估计降压治疗对主要心血管事件（卒中、缺血性心脏病或心力衰竭）复合终点的影响。此外，为评估基线时伴有和不伴有 AF 的患者中降压强度与心血管结局之间的关联是否相似，我们采用了荟萃回归分析。从完整的 BPLTTC 数据库中，排除了 28 项研究（145653 名参与者），因为基线时的 AF 状态不确定或无法获得。共有 22 项研究纳入了 188570 名患者，其中 13266 名（7%）患者基线时患有 AF。偏倚风险评估显示，20 项研究的偏倚风险较低，2 项研究的偏倚风险中等。荟萃回归显示，基线时伴有和不伴有 AF 的患者中，降压治疗的相对风险降低与试验水平的降压强度呈比例关系。在中位数为 4.5 年的随访期间，收缩压（SBP）降低 5mmHg 可降低伴有 AF 的患者（风险比 [HR]0.91，95%置信区间 [CI]0.83 至 1.00）和基线时无 AF 的患者（HR0.91，95%CI0.88 至 0.93）发生主要心血管事件的风险，且亚组间无差异。在基线 SBP 或药物类别方面，基线时伴有 AF 的患者中，治疗效果无异质性。