What do we actually know about the relationship between arterial hypertension and atrial fibrillation?

Figures & data

Table I. The impact of hypertension on atrial fibrillation (AF) occurrence.

Reference	Sample size and subjects included in the study	Main findings
Grundvold et al. (9)	2014 healthy men	Upper normal systolic BP was long-term predictor of incident AF in initially healthy middle-aged men
Framingham Heart Study (34)	5331 subjects older than 35 years without AF at the beginning of study	Systolic and pulse BP were risk factors for AF development
LIFE study (35)	8810 hypertensive patients with electrocardiographic evidence of left ventricular hypertrophy	Systolic, diastolic and pulse BP were predictors of new-onset AF
ONTARGET–TRANSCEND study (36)	30,424 patients with complicated diabetes or vascular disease who were in sinus rhythm at entry	Systolic and pulse BP, left ventricular hypertrophy, and hypertension were associated with AF development
Women's Health Study (37)	34,221 healthy women	Systolic BP was a better predictor than diastolic BP for AF occurrence
BAFTA study (38)	106,258 participants older than 75 years	Hypertension is very common in older patients with AF. The mean systolic BP is slightly lower, but the mean diastolic BP is substantially higher in older patients in AF, compared with the general population
Thacker et al. (39)	1385 patients aged 30–84 with newly diagnosed AF	Risk of permanent AF was similar for patients with and without hypertension and across BP levels
Pierdomenico et al. (40)	1141 patients aged ≥ 40 years with sustained hypertension	Non-dipper sustained hypertensive patients have a two-fold greater risk of developing AF than dippers
Webb & Rothwell (41)	125,878 treated hypertensive patients	Variability in BP was not related with risk of new-onset AF

BP, blood pressure; LIFE, Losartan Intervention for Endpoint Reduction in Hypertension; ONTARGET, Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial; TRANSCEND, Telmisartan Randomized Assessment Study in ACE Intolerant subjects with Cardiovascular Disease; BAFTA, Birmingham Atrial Fibrillation in the Aged.

Table II. The studies of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) for prevention of atrial fibrillation (AF) in hypertensive patients for prevention of AF in different patient populations.

Reference	Treatment	No. of patients	Age (years)	Main findings
STOP-H2 (43)	Enalapril and lisinopril vs CCB	6616	76	There is no difference in AF occurrence between different ACEIs, or in comparison with CCBs.
CAPPP (44)	Captopril vs BB± diuretics	10,985	52.6 ± 8.4	Captopril and conventional treatment (BBs± diuretics) did not differ in efficacy in AF preventing.
L’Allier et al. (45)	ACEI vs CCB	10,926	65	ACEIs significantly more reduced risk of AF development.
LIFE (46)	Losartan vs atenolol	9193	66.9 ± 7	New-onset AF was significantly reduced by losartan- compared with atenolol-based antihypertensive treatment with similar blood pressure reduction.
VALUE (47)	Valsartan vs amlodipine	15,245	70.5 ± 7.4	Valsartan-based treatment reduced the risk of new-onset AF compared with amlodipine-based therapy.
PRoFESS (48)	Telmisartan vs placebo	20,332	66.1 ± 8.6	Telmisartan reduced the risk of AF development in comparison with placebo.
ONTARGET (49)	Telmisartan vs ramipril	25,620	66.4 ± 7.2	New-onset of AF was slightly less frequent with the telmisartan-based than with the ramipril-based treatment.
GISSI – AF (50)	Valsartan vs placebo	1442	67.8 ± 9.2	Treatment with valsartan was not associated with a reduction in the incidence of recurrent AF.
Fogari et al. (51)	Valsartan vs ramipril	369	64 ± 7	Despite similar BP lowering, valsartan and ramipril were more effective than amlodipine in preventing new episodes of AF, but valsartan was more effective than ramipril.
Fogari et al. (52)	Losartan vs amlodipine	213	63.4 ± 7.9	Losartan in combination with amiodarone was more effective than amlodipine/amiodarone combination in preventing new episodes of AF.
Galzerano et al. (53)	Telmisartan vs carvedilol	132	55.8	Telmisartan was significantly more effective than carvedilol in preventing recurrent AF episodes.

CCB, calcium channel blocker; BB, beta-blocker; STOP-Hypertension 2, Swedish Trial in Old Patients with Hypertension 2; CAPP, Captopril Prevention Project; LIFE, Losartan Intervention for Endpoint Reduction in Hypertension; VALUE, Valsartan Antihypertensive Long-term Use Evaluation; ProFESS, Prevention Regimen for Effectively Avoiding Second Strokes; ONTARGET, Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial; GISSI-AF, Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico-Atrial Fibrillation.

Table III. The studies meta-analyses of renin–angiotensin–aldosterone system (RAAS) blockade for prevention of atrial fibrillation (AF) in different patient populations.

Reference	No. of patients	Main findings
Disertori et al. (54)	4395	ARBs in secondary prevention of AF are not effective, whereas there are no strong enough data for a conclusion about ACEIs effectiveness.
Huang et al. (55)	91,381	ACEIs and ARBs are effective for primary and secondary prevention of AF, especially in patients with hypertension.
Lally et al. (56)	59,828	Blockade of RAAS reduced AF occurrence.
Healey et al. (58)	56,308	ACEIs and ARBs were effective in the prevention of AF, especially in patients with LVH or systolic left ventricular dysfunction.
Kalus et al. (59)	15,616	RAAS blockers were associated with a reduction in new-onset atrial fibrillation, a lower failure rate of electrical cardioversion of AF, and a lower rate of AF recurrence after electrical cardioversion.
Schneider et al. (60)	87,048	RAAS inhibition was effective for the primary and secondary prevention of AF.
Bhuriya et al. (61)	2323	ACEs and ARBs were associated with a significant reduction in recurrent AF.
Zhang et al. (62)	67,329	The preventive effect was similar between ACEIs and ARBs, but preventive effects was greater regarding recurrent AF than new-onset AF.

ARB, angiotensin receptor blocker; ACEI, angiotensin-converting enzyme inhibitor; LVH, left ventricular hypertrophy.

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