Heart Views

: 2005  |  Volume : 6  |  Issue : 1  |  Page : 18--23

Pretreatment with ACE inhibitors improves outcome of electrical cardioversion in patients With presistent atrial fibrillation

Trudeke Van Noord1, Harry JGM Crijns2, Maarten P van den Berg1, Dirk J Van Veldhuisen1, Isabelle C Van Gelder1,  
1 Department of Cardiology, Thoraxcenter, University Hospital Groningen, Groningen, Netherlands
2 Department of Cardiology, University Hospital Maastricht, Maastricht, Netherlands

Correspondence Address:
Trudeke Van Noord
Department of Cardiology, Thoraxcenter, University Hospital Groningen, Groningen


Background: Persistent atrial fibrillation (AF) is difficult to treat. In the absence of class I or III antiarrhythmic drugs sinus rhythm is maintained in only 30% of patients during the first year after electrical cardioversion (ECV). One of the remodeling processes induced by AF is fibrosis, which relates to inducibility and maintenance of AF. The renin-angiotensin system may play a important role in this. The aim of this study was to investigate the role of angiotensin-converting enzyme (ACE) inhibitor use on efficacy of ECV, and occurrence of subacute recurrences. Methods: One hundred-seven consecutive patients with persistent AF underwent ECV. In twenty-eight (26%) patients ACE inhibitors had been started before initiation of the present episode of AF («SQ»pre-treated«SQ» patients). Results: ECV was successful in 96% of patients who were on ACE inhibitors before start of the present episode of AF compared to 80% of the patients not pre-treated (p = 0.04). After 1 month of follow-up 49% of the pre-treated patients and 50% of those not pre-treated with ACE inhibition were still in sinus rhythm (p=ns). Multivariate analysis showed that pre-treatment with ACE inhibitors and a smaller left atrial size were independent predictors of successful ECV (OR = 5.8, C.I. 1.3-26.1, and OR = 5.6, C.I. 1.2-25.3, respectively). Conclusions: Pre-treatment with ACE inhibitors may improve acute success of ECV but does not prevend AF recurrences.

How to cite this article:
Noord TV, Crijns HJ, den Berg MP, Van Veldhuisen DJ, Van Gelder IC. Pretreatment with ACE inhibitors improves outcome of electrical cardioversion in patients With presistent atrial fibrillation.Heart Views 2005;6:18-23

How to cite this URL:
Noord TV, Crijns HJ, den Berg MP, Van Veldhuisen DJ, Van Gelder IC. Pretreatment with ACE inhibitors improves outcome of electrical cardioversion in patients With presistent atrial fibrillation. Heart Views [serial online] 2005 [cited 2021 Apr 19 ];6:18-23
Available from: https://www.heartviews.org/text.asp?2005/6/1/18/64001

Full Text


Persistent atrial fibrillation (AF) is difficult to treat. In the absence of class I or III antiarrhythmic drugs, sinus rhythm is maintained in only 30-50% of patients during the first year after Direct Current electrical cardioversion (ECV) [1],[2] . Furthermore, even following an aggressive approach with repeated ECVs and use of prophylactic drugs, arrhythmia-free outcome is still poor: only 39% of patients maintain sinus rhythm during two years of follow-up [1],[2] .

Notwithstanding the recent results of AFFIRM and RACE showing no beneficial effect of rhythm control over rate control, a rhythm control strategy may be indicated in severely symptomatic patients and those with a tachycardiomyopathy [3] . In recent years, research has focused on the atrial remodeling processes that are induced by AF itself and that trigger the arrhythmia to become sustained: "AF begets AF" [4] . One of the remodeling processes induced by AF is fibrosis. Fibrosis causes dispersion of conduction, which, in its turn is related to inducibility of AF [5] . The renin-angiotensin system seems to play an important role in the development of fibrosis in heart failure. It was shown that pre-treatment with enalapril may attenuate atrial fibrosis and conduction abnormalities in a canine model of heart failure, and the occurrence of AF in patients with left ventricular dysfunction [5],[6],[7] . A recent experimental study showed that angiotensin II blockers may prevent electrical remodeling when started before start of AF [8] .

In the present study we report on the effects of ACE inhibition on the outcome of ECV and the prevention of early recurrences after ECV of persistent AF.


One hundred-seven consecutive patients with persistent AF, defined as the presence of AF for at least 24 hours were included in this study [9] . ECV was performed according to a previously described step up protocol [10] . Successful ECV was defined as the presence of sinus rhythm for at least 4 hours after ECV. No difference was made between unsuccessful ECV due to shock failure or due to an immediate recurrence of AF (within 2 minutes after successful ECV).

ACE pre-treatment was defined as use of ACE inhibitors before onset of the current AF episode. Most patients on ACE inhibitors used these drugs for hypertension or congestive heart failure. To make sure that all patients were not completely remodeled at the very moment of start of the current episode of AF (and thereby verifying the fact that they were treated with ACE inhibitors before the process of electrical remodeling started), only patients with at least 1 month sinus rhythm before the current episode of AF were included in this study. Duration of AF was determined as precisely as possible by previous electrocardiograms, 24-hour Holter registrations, and by the patient's history. None of the patients were on class I or III antiarrhythmic drugs at the moment of ECV or during follow-up.

 Statistical analysis

Quantitative variables were compared between groups using a two-tailed t-test for normally distributed variables or a Wilcoxon two-sample test for skewed distributed variables. For qualitative variables (categorical or ordered), group differences were evaluated using a Fisher's exact test or a Chi-square test. Accordingly, baseline characteristics are given in mean ΁ SD, median and range (min-max) or percentages.

To determine the predictive factors for successful ECV, an univariate logistic regression analysis was performed using the relevant baseline predictors. Variables with a p-value Main results

This post-hoc retrospective analysis shows that use of ACE inhibitors before the onset of AF enhances acute ECV outcome but it does not improve maintenance of sinus rhythm. Furthermore, when ACE inhibitiors are instituted later, i.e. after the start of AF, it does no longer improve success of ECV.

Effect of ACE-inhibition on structural remodeling

ACE inhibitors reduce the incidence of AF in patients with left ventricular dysfunction [7],[6] . This may be related to the protective effects of ACE inhibitors, which help to maintain atrial integrity and attenuate fibrosis [5] . In the present study pre-treatment with an oweve How ACE inhibitor (i.e. use of ACE inhibitors before onset of the arrhythmia) improved acute outcome of ECV. In view of the above, this suggests that ACE inhibitors may prevent or diminish AF induced structural remodeling. These clinical findings are compatible with experimental findings showing that ACE-inhibition could attenuate heart failure induced atrial functional remodeling and fibrosis in dogs [11] . In atrial tissue from AF patients an ACE-dependent increase of activated extracellular signal-regulated kinase (Erk) type 1 and 2 was found, which may contribute to the development of atrial fibrosis during AF [12] .

Effect of ACE-inhibition on electrical remodeling

In 1995 it was shown that AF induces several electrophysiological changes, called electrical remodeling [4] . Experimental data show that ACE inhibition prevents short-term ( [8],[13] . However, enalapril could not attenuate or prevent the long-term (7 days) effects of tachycardia on remodeling [8] . Several studies have investigated the role of calcium channel blockers on electrical remodeling. In these studies it was also shown that although there was a short-term prevention of electrical remodeling, calcium channel blockers did not have a long-term protective effect on electrical remodeling [14],[15],[16] .

Effect on AF recurrences

Madrid et al. investigated the role of the angiotensin II type 1 receptor antagonist irbesartan in amiodarone treated patients [17] . Persistent AF patients were randomized to either treatment with amiodarone alone or treatment with amiodarone in combination with irbesartan. Drug treatment was started at least 3 weeks before cardioversion but after the start of AF. No differences were found in electrical cardioversion outcome between the two treatment groups, which is in contrast to the present study. This may relate to the fact that all patients were in AF at the very moment of start of irbesartan. Two months after cardioversion, it appeared that patients treated with irbesartan and amiodarone had a significantly lower AF recurrence rate compared to amiodarone alone treated patients, 15% versus 37%, respectively (p = 0.007). This difference was maintained during a median follow-up of 254 days. According to their [Figure 2], the benefit of irbesartan (in combination with amiodarone) was mainly achieved by reduction of recurrences after the first two weeks after cardioversion. An earlier study on the role of ACE inhibitors in patients with heart failure and AF showed a trend towards more patients maintaining sinus rhythm after ECV when instituted on lisinopril in comparison to patients not treated with lisinopril [18] . In the present study no difference in recurrence rate could be found between patients with and without ACE-pretreatment.

 Limitations of the study

This was a non-randomized and post-hoc analysis. This implies that all findings can only be used to generate hypotheses. However, this is the first clinical study showing that ACE-inhibition initiated before start of AF enhances direct ECV outcome.

Only a very small number of patients were on angiotensin receptor blockers. Whether the effect of pretreatment with angiotensin receptor blockers on cardioversion outcome would be similar as the effect of pretreatment with ACE inhibitors could not be investigated in this study. However, in this context the results of the study of Madrid et al. are encouraging [17] .


Pretreatment with ACE-inhibitors significantly improves acute outcome of ECV when initiated before the onset of AF but it does not lead to better maintenance of sinus rhythm. When ACE inhibitiors are, however, instituted later, i.e. after the start of AF, it does no longer improve success of ECV.


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