Association of pretreatment with angiotensin-converting enzyme inhibitors with improvement in ablation outcome in atrial fibrillation patients with low left ventricular ejection fraction

Sanghamitra Mohanty; Prasant Mohanty; Chintan Trivedi; Carola Gianni; Rong Bai; John David Burkhardt; Joseph G Gallinghouse; Rodney Horton; Javier E Sanchez; Patrick M Hranitzky; Amin Al-Ahmad; Shane Bailey; Luigi Di Biase; Andrea Natale

doi:10.1016/j.hrthm.2015.06.007

Association of pretreatment with angiotensin-converting enzyme inhibitors with improvement in ablation outcome in atrial fibrillation patients with low left ventricular ejection fraction

Heart Rhythm. 2015 Sep;12(9):1963-71. doi: 10.1016/j.hrthm.2015.06.007. Epub 2015 Jun 5.

Affiliations

¹ Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas.
² Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
³ Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
⁴ Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Department of Biomedical Engineering, University of Texas at Austin, Austin, Texas.
⁵ Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Department of Biomedical Engineering, University of Texas at Austin, Austin, Texas; Albert Einstein College of Medicine at Montefiore Hospital, New York, New York; University of Foggia, Foggia, Italy.
⁶ Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Department of Biomedical Engineering, University of Texas at Austin, Austin, Texas; Interventional Electrophysiology, Scripps Clinic, San Diego, California; Department of Internal Medicine, Dell Medical School, Austin, Texas; Division of Cardiology, Stanford University, Palo Alto, California; California Pacific Medical Center, San Francisco, California; Case Western Reserve University, Cleveland, Ohio; Albert Einstein College of Medicine at Montefiore, New York, New York. Electronic address: [email protected].

PMID: 26051531
DOI: 10.1016/j.hrthm.2015.06.007

Abstract

Background: Angiotensin-converting enzyme inhibitors (ACEIs) reduce the incidence of atrial fibrillation (AF).

Objective: The purpose of this study was to assess the impact of upstream ACEI therapy on postablation AF recurrence and hospitalization in patients with low left ventricular ejection fraction (LVEF).

Methods: Three hundred forty-five consecutive patients undergoing first AF ablation with low LVEF (≤45%) were classified into group 1 (ACEI+, n = 187 [54%], of whom 44 patients [23.5%] had paroxysmal AF [PAF]) or group 2 (ACEI-, n = 158 [46%]; 31 of these 158 patients [19.6%] had PAF). Additionally, 703 consecutive patients with LVEF >45% undergoing first AF ablation were included for a secondary analysis to evaluate the effect of ACEI treatment in normal ejection fraction. In group 1, ACEI therapy started ≥3 months before ablation and continued through follow-up.

Results: Baseline characteristics were similar except for hypertension, which was significantly more prevalent in ACEI+ (71% vs 51%, P < .001). At 24 ± 7 months of follow-up, 109 nonparoxysmal AF patients in group 1 (76%) and 81 (64%) in group 2 (P = .015) were recurrence free. In multivariate analysis, ACEI therapy was an independent predictor of recurrence (hazard ratio for ACEI-, 1.7, 95% confidence interval 1.1-2.7; P = .026]. However, among PAF patients, ACEI use was not associated with ablation success (80% vs 77% in ACEI+ and ACEI-, respectively; P = .82). In the normal-EF population, the success rates between ACEI+ and ACEI- cohorts were similar (71% vs 74%, P = .31). After the index procedure, 17 patients (9.1%) in the ACEI+ group and 28 (17.7%) in the ACEI- cohort (P= .02) required rehospitalization, for a 49% relative risk reduction (relative risk 0.51, 95% confidence interval 0.29-0.90).

Conclusion: Preablation use of an ACEI is associated with improvement in ablation outcome in patients with nonparoxysmal AF with low LVEF.

Keywords: AF-related hospitalization; Ablation outcome; Angiotensin-converting enzyme inhibitors; Low left ventricular ejection fraction; Nonparoxysmal atrial fibrillation.

MeSH terms

Adolescent
Adult
Aged
Aged, 80 and over
Angiotensin-Converting Enzyme Inhibitors / therapeutic use*
Atrial Fibrillation / epidemiology
Atrial Fibrillation / physiopathology
Atrial Fibrillation / therapy*
Catheter Ablation / methods*
Female
Follow-Up Studies
Humans
Incidence
Male
Middle Aged
Preoperative Care / methods*
Prospective Studies
Stroke Volume / drug effects*
Survival Rate / trends
Time Factors
Treatment Outcome
United States / epidemiology
Ventricular Function, Left / drug effects*
Young Adult

Substances

Angiotensin-Converting Enzyme Inhibitors