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. 2023;30(2):312-326.
doi: 10.5603/CJ.a2022.0061. Epub 2022 Jun 28.

Atrial fibrillation in heart failure patients: An update on renin-angiotensin-aldosterone system pathway blockade as a therapeutic and prevention target

Ioanna Koniari  1 , Eleni Artopoulou  2 , Virginia Mplani  3 , Francesk Mulita  4 , Evangelia Alexopoulou  2 , Emmanouil Chourdakis  5 , Mohammed Abo-Elseoud  1 , Grigorios Tsigkas  3 , Ioannis Panagiotopoulos  6 , Nicholas Kounis  3 , Dimitrios Velissaris  2
Affiliations

Atrial fibrillation in heart failure patients: An update on renin-angiotensin-aldosterone system pathway blockade as a therapeutic and prevention target

Ioanna Koniari et al. Cardiol J. 2023.

Abstract

Heart failure (HF) and atrial fibrillation (AF) are two cardiovascular (CV) entities that affect millions of individuals worldwide and their prevalence is translated into a significant impact on health care systems. The common pathophysiological pathways that these two share have created an important clinical interrelation, as the coexistence of HF and AF is associated with worse prognosis and treatment challenges. Renin-angiotensin-aldosterone system (RAAS), a critical mechanism in blood pressure (BP) control, was proved to be involved in the pathogenesis of both conditions contributing to their further coexistence. Successful control of BP is of great importance to the management of HF, crucial for the prevention of arrhythmiogenic substrates, while RAAS antagonists may possibly affect the development of new-onset AF as well. There are numerous studies that evaluated the effectiveness of RAAS blockade in AF/HF population and despite comparable or modest results, there is a well-established suggestion that RAAS blockers may contribute to a reduction of HF, CV events and recurrence of AF, along with their potential effective role in the new-onset AF prophylaxis. Angiotensin receptor blockers, according to the evidence, are more effective in that direction, followed by angiotensin converting enzyme inhibitors, whereas the data on aldosterone antagonists are not encouraging, yet do have the potential of significant CV disease modificators regardless of their effects on BP.

Keywords: aldosterone antagonists (AAs); angiotensin converting enzyme inhibitors (ACEIs); angiotensin receptor blockers (ARBs); atrial fibrillation; heart failure; renin–angiotensin–aldosterone system (RAAS) blockers.

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Conflict of interest statement

Conflict of interest: None declared

Figures

Figure 1
Figure 1
Management algorithm in patients with heart failure (HF) and/or no concomitant atrial fibrillation (AF) and class of recommendation based on European Society of Cardiology HF, AF and pacing/cardiac resynchronization therapy (CRT) guidelines; ACE-I — angiotensin converting enzyme inhibitors; ARB — angiotensin receptor blockers; ICD — implantable cardioverter defibrillator; ARNI — angiotensin receptor-neprilysin inhibitor AVJ — atrioventricular junction; LBBB — left bundle branch block; HFrEF — HF with reduced ejection fraction; HFmrEF — HF with mildly reduced ejection fraction; HFpEF — HF with preserved ejection fraction; LVEF — left ventricular ejection fraction; MRAs — mineralocorticoid receptor antagonists; RAAS — renin–angiotensin–aldosterone system; SR — sinus rhythm; HR — heart rate.
Figure 2
Figure 2
Management of atrial fibrillation (AF) population with renin–angiotensin–aldosterone system upstream therapy; AAs — aldosterone antagonists; ACEI — angiotensin converting enzyme inhibitors; ARBs — angiotensin receptor blockers; MRAs — mineralocorticoid receptor antagonists; LV — left ventricular.
Figure 3
Figure 3
Central illustration. The renin–angiotensin–aldosterone system (RAAS) system and stages of inhibition by angiotensin converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors, aldosterone antagonists; HFpEF — heart failure with preserved ejection fraction; NS — nervous system.
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