Abstract
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. 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. 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.
Highlights
Atrial fibrillation (AF) is the most common clinically relevant cardiac arrhythmia and its incidence and prevalence are on the rise across the globe [1,2], mainly due to population ageing and an increase in other cardiometabolic risk factors [3]
Over 4.5 years of median follow-up, a 5-mm Hg systolic blood pressure (BP) (SBP) reduction lowered the risk of major cardiovascular events both in patients with AF and in patients without AF at baseline (HR 0.91, 95% confidence interval (CI) 0.88 to 0.93), with no difference between subgroups
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. In this meta-analysis, we found that BP-lowering treatment reduces the risk of major cardiovascular events in individuals with and without AF
Summary
Atrial fibrillation (AF) is the most common clinically relevant cardiac arrhythmia and its incidence and prevalence are on the rise across the globe [1,2], mainly due to population ageing and an increase in other cardiometabolic risk factors [3]. High blood pressure (BP) is the most common cardiovascular risk factor in patients with AF [8,9], whether BP lowering reduces the risk of cardiovascular events in patients with AF remains uncertain. The complex structural, neurohumoral, and metabolic changes in the cardiovascular system that underpin the development and progression of AF may interfere with BP-lowering treatment [11]. This uncertainty is further compounded by the fact that the only randomised controlled trial (RCT) conducted in patients with AF failed to detect a risk reduction in cardiovascular events using an angiotensin receptor blocker [12]. This study aimed to compare the effects of BP-lowering drugs in patients with and without AF at baseline
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