Renin Angiotenin Blocker Pre-treatment and Recurrence After Pulmonary Vein Isolation in Patients with Paroxysmal and Persistent Atrial Fibrillation.

Abstract

Introduction: Pulmonary venous isolation has emerged as an effective method for preventing atrial fibrillation (AF) recurrence. Yet, recurrence is common. Angiotensin-receptor-blockers (ARBs) and angiotensin-converting-enzyme-inhibitors (ACEI) are effective in reducing the extent of myocardial remodeling and fibrosis. Our aim was to study whether pretreatment with ARBs and ACEI was effective in decreasing recurrence after pulmonary vein isolation for patients with AF. Methods: Three hundred and twelve consecutive patients who underwent ablation from 12/2006 until 7/2010 were followed for at least one year. All patients underwent MRI before ablation to assess atrial fibrosis. Data include demographic characteristics, comorbidities, AF type and information regarding treatment with ACEI or ARBs. Results: Most patients were men (62%), mean age was 64. Hypertension (HTN) was present in 60%. Their mean ejection fraction was 60%. There were 104 patients (33.3%) treated with ACEI, and 13.5 % were treated with ARBs prior to ablation. Ninety seven patients (31.1%) had AF recurrence. AF type was a significant predictor for recurrence (recurrence with paroxysmal, persistent and long-standing persistent: 23.75, 37.3 and 60%, respectively, p=0.005). The most important factor predicting recurrence was increased pre-ablation atrial fibrosis (p<0.0001). Recurrence was more frequent in patients treated with ACEI (40.4% vs 26.4% untreated patients, p=0.012). In the ARB treated group, 38.1% vs 30.0% untreated experienced recurrence (p=0.3). After multivariable adjustment for demographics, risk factors and atrial fibrosis, treatment with ACEI was associated with increased rate of recurrence in patients with persistent AF (hazard ratio: 2.6, p=0.003). There was no significant relation between ACEI pretreatment and recurrence in patients with paroxysmal AF (HR- 0.83, p=0.7), or between ARB pre-treatment and recurrence in patients with paroxysmal as well as persistent AF (p=0.2 and 0.53, respectively). Conclusions: Pretreatment with ACEI or ARBs is not associated with reduced recurrence rate in patients with paroxysmal or persistent AF undergoing ablation.