Indirect antiarrhythmic effects of renin-angiotensin-aldosterone system inhibition for arrhythmia recurrence prevention after electrical cardioversion for persistent atrial fibrillation

Electrical cardioversion (ECV) is quick and effective method for rhythm control in atrial fibrillation (AF) patients. Nevertheless, long-term results are modest, especially with progression of remodelling, including major contribution of renin-angiotensin-aldosterone system (RAAS), which could be a target to attenuate arrhythmia relapse. Aim was to evaluate effects of RAAS inhibition by angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) and mineralocorticoid receptor antagonists (MRAs) for arrhythmia recurrence prevention after ECV in patients with persistent AF. Prospective research was conducted among patients with persistent or longstanding persistent AF undergoing ECV in the Latvian Centre of Cardiology. Baseline face-to-face interview was conducted, according to data collection protocol, with subsequent 1-, 3-, 6-, 9- and 12-month follow-up, focusing on sinus rhythm maintenance and medication persistence. Data analysis was carried out with MS Excel and SPSS Statistics software (α=0.05). Among 103 participants, 93.2% had persistent AF and 6.8% – longstanding persistent type, with total arrhythmia recurrence rate 46.6%. Each month of AF history was established to increase AF recurrence likelihood by 2.1% (OR=1.021, 95%CI 1.008-1.034, p=0.001), nevertheless no significant impact of current arrhythmia episode duration in weeks prior to ECV was found (OR=1.004, 95%CI 0.993-1.014, p=0.507). Regarding RAAS inhibiting medications, ACEI/ARB therapy, compared to non-use, showed no significant contribution to AF relapse prevention (OR=0.897, 95%CI 0.358-2.250, p=0.817), whereas MRA intake was linked to decreased odds for AF recurrence by 72.9% (OR=0.271, 95%CI 0.098-0.751, p=0.012). With AF history and MRA intake as variables in regression model, present MRA therapy was associated with reduced prospects for AF relapse by 75.7% (OR=0.243, 95%CI 0.078-0.757, p=0.015), when adjusted to AF history. Prolonged AF history is associated with impaired long-term sinus rhythm maintenance prognosis, presumably attributed to remodelling progression. RAAS inhibition by MRAs has demonstrated significant contribution to arrhythmia recurrence prevention via indirect antiarrhythmic action, with potentially emphasized chronic use.