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Treatment of hypertension to prevent atrial fibrillation

An article from the e-journal of the ESC Council for Cardiology Practice

Hypertension is an important treatment target for prevention of atrial fibrillation. Hypertension may trigger hypertrophy, not only of the left ventricle but also of the left atrium. The latter predisposes to atrial fibrillation but also to thrombosis and systemic embolism from the left atrium.

Atrial Fibrillation


The cardiovascular risks of untreated hypertension have been described extensively. Stroke, coronary heart disease, congestive heart failure and renal dysfunction are the chief risks in hypertension. The coexistence of atrial fibrillation and hypertension is well known: hypertension leads to remodeling of the left atrium such that a favorable substrate for atrial fibrillation develops. Treatment of hypertension to prevent atrial fibrillation and its complications is not yet, however, a common strategy. Two interesting papers have been published recently on this subject: The first1 outlines the epidemiological characteristics of the relation; the second2 stresses the need for treatment of hypertension to prevent atrial fibrillation.

In an Italian study1 2482 subjects with essential hypertension were followed for up to 16 years. This is a sub study of the PIUMA study, an observational registry of morbidity and mortality in initially untreated subjects with essential hypertension. The goal was to further elucidate the role of hypertension in the occurrence of atrial fibrillation with respect to predictors and outcome. Related to the control population, the future atrial fibrillation patients had upon entering the study, a higher age, an increased body mass index, an increased left ventricular mass, a higher systolic blood pressure and a lower heart rate than the control population. However, the only independent risk factors were higher age and increased left ventricular mass. Predictors for chronic atrial fibrillation were increased age and left ventricular mass, but especially an increased left atrial diameter.

As left ventricular hypertrophy and left atrial enlargement are risk factors for atrial fibrillation, it is postulated2 that regression of left ventricular hypertrophy and left atrial enlargement by vigorous treatment with antihypertensive drugs could decrease the risk for atrial fibrillation. Especially ACE-inhibitors and calcium antagonists are known to show more regression of left ventricular hypertrophy independent of blood pressure lowering. The risk for stroke, the major complication of both atrial fibrillation and hypertension can be reduced by 30-40% in patients with hypertension. This indicates that treatment of hypertension is even more warranted in subjects prone to developing atrial fibrillation.
Recently, two papers show the relation between atrial fibrillation and hypertension. They indicate that by treating hypertension, not only may cardiovascular disease be prevented but atrial fibrillation and its complications may be prevented as well. However, further research to determine the effect of antihypertensive drugs on the primary prevention of atrial fibrillation will be needed.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

References


1. Verdecchia et al. “Atrial Fibrillation in Hypertension; Predictors and Outcome”, Hypertension. 2003; 41: 218-223
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12574085&dopt=Abstract

2. Healey et al, "Atrial Fibrillation: Hypertension as a Causative Agent, Risk Factor for Complications, and Potential Therapeutic Target” Am J Cardiol. 2003 May 22; 91(10A):9-14
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12781903&dopt=Abstract

Notes to editor


Dr S.Winckels and Pr H.Crijns
ESC fellows and nucleus member of the ESC Working Group on Arrhythmias

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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