European Heart Journal Advance Access originally published online on September 11, 2006
European Heart Journal 2006 27(19):2370-2371; doi:10.1093/eurheartj/ehl242
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Anti-inflammatory effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: potential benefits for the prevention of atrial fibrillation
Department of Cardiology
Tianjin Institute of Cardiology
2nd Hospital of Tianjin Medical University
Tianjin 300211
People's Republic of China
Tel: +86 22 88328617
Fax: +86 22 28261158
E-mail address: liutongdoc{at}yahoo.com.cn
Department of Cardiology
Tianjin Institute of Cardiology
2nd Hospital of Tianjin Medical University
Tianjin 300211
People's Republic of China
We read with great interest the recent prospective randomized study by Yin et al.,1 which suggested that the combination of perindopril or losartan with low-dose amiodarone is more effective than amiodarone alone for the prevention of atrial fibrillation (AF) recurrence in patients with lone paroxysmal AF. The investigators proposed several underlying mechanisms by which the renin–angiotensin–aldosterone system (RAAS) blockade with these agents might prevent AF recurrence, such as reversing atrial electrical remodelling and inhibition of structural remodelling by reducing left atrial dilation. We agree that the modification of atrial remodelling by perindopril and losartan may be the main mechanism for AF prevention.
We would like to provide another potential mechanism in this setting. Recently, the role of inflammation in the genesis and perpetuation of AF has been evaluated.2 First, atrial biopsies from 12 patients with lone AF have showed evidence of myocarditis compared with controls. Then, numerous clinical studies have demonstrated that inflammatory biomarker C-reaction protein (CRP) was increased in patients with paroxysmal AF and much more elevated in patients with persistent AF, and baseline CRP also predicts patients at increased risk for developing future AF. Furthermore, anti-inflammatory interventions such as statins, steroids, fish oils, and vitamin C, have shown favourable effects in the prevention and treatment of AF.2,3 In contrast, accumulating evidence suggested angiotensin II has significant pro-inflammatory activity that induced the expression of inflammatory cytokines, adhesion molecules, and reactive oxygen species.4 Recently, the European Trial on Olmesartan and Pravastatin in Inflammation and Atherosclerosis found that in patients with essential hypertension, angiotensin II receptor blockade significantly reduced serum levels of CRP, tumour necrosis factor-alpha, interleukin-6, and monocyte chemotactic protein-1.5 Inhibition of RAAS by either ramipril or telmisartan also suppressed inflammatory markers in non-hypertensive diabetic patients.6 Therefore, we assume that anti-inflammatory effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may favourably prevent AF recurrence in patients with lone paroxysmal AF. If Yin et al. could provide us with the baseline and follow-up CRP levels in their lone AF patients, our hypothesis will be supported.
References
- Yin Y, Dalal D, Liu Z, Wu J, Liu D, Lan X, Dai Y, Su L, Ling Z, She Q, Luo K, Woo K, Dong J. (2006) Prospective randomized study comparing amiodarone vs. amiodarone plus losartan vs. amiodarone plus perindopril for the prevention of atrial fibrillation recurrence in patients with lone paroxysmal atrial fibrillation. Eur Heart J 27:1841–1846.
[Abstract/Free Full Text] - Boos CJ, Anderson RA, Lip GY. (2006) Is atrial fibrillation an inflammatory disorder? Eur Heart J 27:136–149.
[Abstract/Free Full Text] - Liu T and Li GP. (2006) New evidence of anti-inflammatory interventions in atrial fibrillation. Eur Heart J 27:500.
[Free Full Text] - Ferrario CM and Strawn WB. (2006) Role of the renin–angiotensin–aldosterone system and proinflammatory mediators in cardiovascular disease. Am J Cardiol 98:121–128.[CrossRef][Web of Science][Medline]
- Fliser D, Buchholz K, Haller H. (2004) Antiinflammatory effects of angiotensin II subtype 1 receptor blockade in hypertensive patients with microinflammation. Circulation 110:1103–1107.
[Abstract/Free Full Text] - Koulouris S, Symeonides P, Triantafyllou K, Ioannidis G, Karabinos I, Katostaras T, El-Ali M, Theodoridis T, Vratsista E, Thalassinos N. (2005) Comparison of the effects of ramipril versus telmisartan in reducing serum levels of high-sensitivity C-reactive protein and oxidized low-density lipoprotein cholesterol in patients with type 2 diabetes mellitus. Am J Cardiol 95:1386–1388.[CrossRef][Web of Science][Medline]
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