Meta-analysis: Inhibition of renin-angiotensin system prevents new-onset atrial fibrillation

Background: Epidemiologic studies suggest that inhibition of renin-angiotensin system with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may prevent development of atrial fibrillation (AF). Objective: The objective of the study was to assess if there is significant indication for using angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in the prevention of new-onset AF and to identify the target patient population. Methods: PubMed and Cochrane clinical trials database were searched from 1980 through March 2005 together with the review of citations. Nine randomized controlled human trials reporting the prevention of new-onset AF by inhibition of renin-angiotensin system were identified. Information about study design, follow-up, intervention, population, outcomes, and methodology quality was extracted. Results: The mean follow-up of the studies ranged from 6 months to 6.1 year. The pooled estimate using random effects model was 0.82 (95% CI 0.70-0.97) for prevention of new-onset AF and 0.61 (95% CI 0.46-0.83) for primary prevention of AF. The angiotensin-converting enzyme inhibitors (0.75, 95% CI 0.57-0.99) had greater protective effect than angiotensin receptor blockers (0.81, 95% CI 0.62-1.06). Patients with heart failure benefited the most (0.57, 95% CI 0.37-0.89). The test for heterogeneity between studies was significant. There was no consistent visual or statistical evidence of publication bias. Conclusion: The use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers had an overall effect of 18% risk reduction in new-onset AF across the trials and 43% risk reduction in patients with heart failure.