Reviewing the future of renin-angiotensin system blockade: The role of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in the prevention of atrial fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice, affecting approximately 250,000 Canadians and accounting for more than 120,000 hospitalizations each year. Atrial remodelling, which is at least partially induced by activation of the renin-angiotensin system (RAS), can be reversed by RAS blockade using angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. While RAS antagonists are not considered to be conventional antiarrhythmic agents, several studies have shown that they may reduce the incidence of AF in patients with heart failure, after myocardial infarction with reduced ejection fraction, and in hypertensive patients. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have also been used in association with amiodarone to facilitate sinus rhythm maintenance after electrical cardioversion. Whether RAS blockade prevents recurrent AF in patients at high cardiovascular risk remains unknown.