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Drug Insight: angiotensin-converting-enzyme inhibitors and atrial fibrillation—indications and contraindications

Nature Clinical Practice Cardiovascular Medicine volume 3, pages 220–225 (2006)Cite this article

Abstract

Large clinical trials have demonstrated that angiotensin-converting-enzyme (ACE) inhibitors are associated with beneficial outcomes in patients with arterial hypertension, heart failure, coronary artery disease, or a combination of these conditions. Other reports have suggested that ACE inhibitors prevent the development or recurrence of atrial fibrillation (AF), a common arrhythmia. In the TRACE trial, in patients with reduced left ventricular function after myocardial infarction, trandolapril reduced the frequency of AF. In the SOLVD trial, a 78% reduction in the frequency of AF after infarction was noted with enalapril compared with placebo. Studies in patients with persistent AF undergoing cardioversion suggest that ACE inhibitors improve outcomes and prevent AF recurrences. The mechanism of AF prevention by ACE inhibitors is unclear, but experimental data show prevention or attenuation of pacing-induced atrial remodeling with ACE inhibitor use. ACE inhibitors decrease angiotensin II concentration; angiotension II stimulates mitogen-activated protein kinases, which in turn activate fibrosis formation and lead to conduction heterogeneity and induction of AF. On the other hand, AF induces atrial dilatation, atrial stretch and atrial secretion of ACE. Among other properties, ACE inhibitors have a sympatholytic effect and increase baroreceptor sensitivity. This review discusses the current data on the use of ACE inhibitors for AF prevention. Although these drugs represent a promising therapeutic option for AF patients, the data so far seem only supportive rather than definitive. Prospective trials are required to validate the benefit of ACE inhibitors and to investigate which patients are most likely to benefit from this pharmacological therapy.

Key Points

  • Atrial fibrillation is associated with disorders, such as arterial hypertension, heart failure and coronary artery disease, for which renin–angiotensin blockade can be beneficial

  • Angiotensin-converting-enzyme inhibition seems experimentally and clinically to prevent the development and recurrence of atrial fibrillation, although the mechanisms remain unclear

  • Attenuation or prevention of atrial remodeling and the prevention of atrial fibrosis are thought to be major beneficial effects of angiotensin-converting-enzyme inhibition

  • Randomized, placebo-controlled trials are required before angiotensin-converting-enzyme inhibitors can be used routinely for atrial fibrillation

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Authors and Affiliations

  1. Professor of Cardiology at France and in the Division of Cardiology, Université de la Méditterranée, School of Medicine, Marseille, Hôpital Nord, Marseille, France

    Samuel Lévy

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Correspondence to Samuel Lévy.

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The author declares no competing financial interests.

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Lévy, S. Drug Insight: angiotensin-converting-enzyme inhibitors and atrial fibrillation—indications and contraindications. Nat Rev Cardiol 3, 220–225 (2006). https://doi.org/10.1038/ncpcardio0480

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