Angiotensin converting enzyme inhibitor and angiotensin receptor blockade use in relation to outcomes in anticoagulated patients with atrial fibrillation.

BACKGROUND

The renin-angiotensin-aldosterone-system (RAAS) plays an important role in atrial fibrillation (AF). Evidence shows that blocking the RAAS with angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) has a definite role in preventing new onset AF and in maintaining sinus rhythm in recurrent AF. Our aim was to determine if ACEI/ARB treatment was associated with clinical outcomes [stroke/systemic embolic events (SEE), mortality] in a controlled, anticoagulated AF population.

METHODS

An ancillary retrospective cross-sectional and longitudinal analysis of participants in the Stroke Prevention using an ORal Thrombin Inhibitor in AF (SPORTIF) III and V trials, in relation to use (or nonuse) of ACEI/ARBs.

RESULTS

Rates of stroke/SEEs, mortality or major bleeding were no different between users and nonusers in the whole cohort, or in relation to the presence/absence of hypertension, coronary artery disease and previous stroke/transient ischaemic attack, nor amongst those aged <75 years. Patients aged > or = 75 years taking ACEIs or ARBs had lower mortality (HR 0.71, 95% CI 0.52-0.95), but no significant influence on other end-points was noted. Diabetics and those with left ventricular dysfunction on ximelagatran had a higher odds ratio of abnormal liver enzyme levels. There was no apparent benefit of ACEIs or ARBs on other event rates.

CONCLUSIONS

This analysis from two large randomized trials of anticoagulation has not demonstrated a significant benefit of ACEI or ARB use amongst AF patients, except amongst elderly subjects.