Statins and new-onset atrial fibrillation in a cohort of patients with hypertension. Analysis of electronic health records, 2006-2015

Effects of statin use on blood pressure and other hypertension-related outcome indicators in hypertensive patients: A systematic review and meta-analysis

AIMS

This meta-analysis delved into the impact of statin therapy, both as a monotherapy and in conjunction with antihypertensive medications, on blood pressure levels and outcomes pertinent to hypertension.

METHODS

We searched the PubMed, EMBASE, and Cochrane databases for studies published before October 1 2023. Studies designed as cohort studies or randomized controlled trials and investigating the effects of single use of statin or its combined use with other antihypertensive therapy were included. Authors extracted the data independently and differences were decided through discussion. Random-effects model was used to evaluate the merged outcomes. Due to the high heterogeneity of the HDL-C group, we performed subgroup analysis according to the type of statin. To assess the robustness and potential publication bias of our findings, we utilized sensitivity analysis, Egger's test, and funnel plots.

RESULTS

23 trials were included in this meta-analysis. The primary outcomes revealed that administering statins did not significantly impact the systolic pressure (SBP) of hypertensive patients (MD, -1.77; 95 % CI, -4.82-1.27). -The promoted effect of statin treatment on diastolic pressure (DBP) in hypertensive patients was found (MD, -1.87; 95 % CI, -3.72 --0.01). The secondary outcomes revealed that the use of statins resulted in a significant reduction in low-density lipoprotein (LDL-C), while significantly increasing high-density lipoprotein (HDL-C) in hypertensive patients.

CONCLUSION

Statin use did not modulate SBP and DBP of patients with hypertension, but SBP was decreased in the rosuvastatin or pravastatin subgroup, while DBP was decreased in the simvastatin or pravastatin subgroup. Statin treatment reduced LDL-C, increased HDL-C, and reduced the incidence of cardiovascular events and mortality compared to control groups.

Mitochondrial Dysfunction in Atrial Fibrillation: The Need for a Strong Pharmacological Approach

Despite great progress in treating atrial fibrillation (AF), especially with the development of increasingly effective invasive techniques for AF ablation, many unanswered questions remain regarding the pathogenic mechanism of the arrhythmia and its prevention methods. The development of AF is based on anatomical and functional alterations in the cardiomyocyte resulting from altered ionic fluxes and cardiomyocyte electrophysiology. Electric instability and electrical remodeling underlying the arrhythmia may result from oxidative stress, also caused by possible mitochondrial dysfunction. The role of mitochondrial dysfunction in the pathogenesis of AF is not yet fully elucidated; however, the reduction in AF burden after therapeutic interventions that improve mitochondrial fitness tends to support this concept. This selected review aims to summarize the mechanisms of mitochondrial dysfunction related to AF and the current pharmacological treatment options that target mitochondria to prevent or improve the outcome of AF.

Effects of statin on hypertension patients: A systematic review and meta-analysis

Objective

To conduct a systematic review and meta-analysis to compare the effects of statins and placebo on systolic blood pressure (SBP) and diastolic blood pressure (DBP) in patients with hypertension.

Methods

We used different databases such as MEDLINE and the Cochrane Library Central Register of Controlled Trials (CENTRAL) to search for randomized controlled trials published from 1 January 2000 to 1 January 2022 to retrieve relevant studies and full-text articles evaluating statins versus placebo in patients with hypertension. Data were taken from eligible studies. The included articles also performed Cochran’s Q statistics, forest plots, funnel plots, Egger’s test, and sensitivity analyses.

Results

This study included 8 studies with a total of 3086 patients. We sought to assess patients' SBP and DBP. The results were expressed as mean differences (MD) with 95% confidence intervals. There was no difference in DBP between the statin and placebo groups (MD = 2.48, 95% CI [−2.00, 6.96], p = .28, random effects model). In terms of SBP, the statin group was superior to the placebo group (MD = 4.37, 95% CI [0.72, 8.02], p = .02, random-effects model). Sensitivity analyses and funnel plots showed that our study was robust, with low publication bias.

Conclusion

The results show that statins could be clinically more effective than placebo in patients with hypertension.

Association between cardiovascular risk factors and atrial fibrillation

Background

The most prevalent sustained arrhythmia in medical practice, atrial fibrillation (AF) is closely associated with a high risk of cardiovascular disease. Nevertheless, the risk of AF associated with cardiovascular risk factors has not been well elucidated. We pooled all published studies to provide a better depiction of the relationship among cardiovascular risk factors with AF.

Methods

Studies were searched in the MEDLINE, Web of Science, and EMBASE databases since initiation until January 15, 2022. Prospective cohort studies assessing the relationship a minimum of single cardiovascular risk factors to AF incidence were included if they contained adequate data for obtaining relative risks (RR) and 95% confidence intervals (CI). Random-effects models were utilized to perform independent meta-analyses on each cardiovascular risk factor. PROSPERO registry number: CRD42022310882.

Results

A total of 17,098,955 individuals and 738,843 incident cases were reported for data from 101 studies included in the analysis. In all, the risk of AF was 1.39 (95% CI, 1.30-1.49) for obesity, 1.27 (95% CI, 1.22-1.32) per 5 kg/m2 for increase in body mass index, 1.19 (95% CI, 1.10-1.28) for former smokers, 1.23 (95% CI, 1.09-1.38) for current smokers, 1.31 (95% CI, 1.23-1.39) for diabetes mellitus, 1.68 (95% CI, 1.51-1.87) for hypertension, and 1.12 (95% CI, 0.95-1.32) for dyslipidemia.

Interpretation

Adverse cardiovascular risk factors correlate with an increased risk of AF, yet dyslipidemia does not increase the risk of AF in the general population, potentially providing new insights for AF screening strategies among patients with these risk factors.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, PROSPERO identifier (CRD42022310882).

Anti-arrhythmic properties of non-antiarrhythmic medications

Traditional anti-arrhythmic drugs are classified by the Vaughan-Williams classification scheme based on their mechanisms of action, which includes effects on receptors and/or ion channels. Some known anti-arrhythmic drugs do not perfectly fit into this classification scheme. Other medications/molecules with established non-anti-arrhythmic indications have shown anti-arrhythmic properties worth exploring. In this narrative review, we discuss the molecular mechanisms and evidence base for the anti-arrhythmic properties of traditional non-antiarrhythmic drugs such as inhibitors of the renin angiotensin system (RAS), statins and polyunsaturated fatty acids (PUFAs). In summary, RAS antagonists, statins and PUFAs are 'upstream target modulators' that appear to have anti-arrhythmic roles. RAS blockers prevent the downstream arrhythmogenic effects of angiotensin II - the main effector peptide of RAS - and the angiotensin type 1 receptor. Statins have pleiotropic effects including anti-inflammatory, immunomodulatory, modulation of autonomic nervous system, anti-proliferative and anti-oxidant actions which appear to underlie their anti-arrhythmic properties. PUFAs have the ability to alter ion channel function and prevent excessive accumulation of calcium ions in cardiac myocytes, which might explain their benefits in certain arrhythmic conditions. Clearly, whilst a number of anti-arrhythmic drugs exist, there is still a need for randomised trials to establish whether additional agents, including those already in clinical use, have significant anti-arrhythmic effects.

A new risk score to assess atrial fibrillation risk in hypertensive patients (ESCARVAL-RISK Project

This study aimed to assess atrial fibrillation (AF) incidence and predictive factors in hypertensive patients and to formulate an AF risk assessment score that can be used to identify the patients most likely to develop AF. This was a cohort study of patients recruited in primary healthcare centers. Patients aged 40 years or older with hypertension, free of AF and with no previous cardiovascular events were included. Patients attended annual visits according to clinical practice until the end of study or onset of AF. The association between AF incidence and explanatory variables (age, sex, body mass index, medical history and other) was analyzed. Finally, 12,206 patients were included (52.6% men, and mean age was 64.9 years); the mean follow-up was 36.7 months, and 394 (3.2%) patients were diagnosed with AF. The incidence of AF was 10.5/1000 person-years. Age (hazard ratio [HR] 1.06 per year; 95% confidence interval [CI] 1.05-1.08), male sex (HR 1.88; 95% CI 1.53-2.31), obesity (HR 2.57; 95% CI 1.70-3.90), and heart failure (HR 2.44; 95% CI 1.45-4.11) were independent predictors (p < 0.001). We propose a risk score based on significant predictors, which enables the identification of people with hypertension who are at the greatest risk of AF.

Hypertension and high ankle brachial index: the overlooked combination

OBJECTIVE

Assessment of asymptomatic organ damage in the management of hypertension includes low (<0.9) ankle brachial index (ABI) values. No recommendations are given for patients with high ABI (≥1.3), despite evidence of an association with increased risk. We aimed to study the association of high ABI with all-cause mortality and cardiovascular outcomes in a hypertensive population.

METHODS

In anonymized clinical records from the Catalan Primary Care (SIDIAP) database, we designed a large cohort of hypertensive patients aged 35-85 years at the start date. Participants were excluded if they had previous heart failure, coronary heart disease, stroke, diabetes mellitus, or chronic kidney disease. The study population was categorized according to ABI values. Cox proportional hazards models were used to assess all-cause mortality, heart failure, acute myocardial infarction, and stroke.

RESULTS

From 2006 through 2015, SIDIAP records included 44 657 hypertensive patients with an ABI measurement 9126 of whom met inclusion criteria. The median follow-up (first to third quartiles) was 6.0 years (4.7-7.6). High ABI (≥ 1.3) was associated with an increase in mortality risk, hazard ratio, and 95% confidence interval: 1.44 (1.10-1.88), similar to the group with ABI at least 0.9 and less than 1.1, hazard ratio 1.36 (1.12-1.65), and lower than all groups with ABI less than 0.9. High ABI values tended to associate with heart failure, hazard ratio 1.34 (0.95-1.91), but the relation of high ABI with acute myocardial infarction and stroke was nonsignificant, hazard ratios 1.30 (0.72-2.35) and 0.97 (0.65-1.42), respectively.

CONCLUSION

Patients with high ABI values and hypertension presented an increased all-cause mortality risk that could be considered when advising such patients.

Blood lipid profiles and risk of atrial fibrillation: A systematic review and meta-analysis of cohort studies

BACKGROUND

There is an increasing body of evidence associating traditional cardiovascular risk factors with atrial fibrillation (AF), but the relationship between blood lipid profiles and the risk of AF remains controversial.

OBJECTIVE

This study aimed to conduct a systemic review and meta-analysis of large cohort studies to evaluate the relationship between blood lipid profiles and incident AF.

METHODS

PubMed and Embase were searched up to January 31, 2019, for cohort studies that reported the relationship between blood lipid levels and incident AF. The hazard ratios or odds ratios of the highest vs lowest categories of lipid levels were extracted to calculate pooled estimates. Sensitivity analysis and meta-regression were performed to explore potential sources of heterogeneity.

RESULTS

Eleven studies were included in the meta-analysis, including 9 studies for total cholesterol (TC), 5 for low-density lipoprotein cholesterol (LDL-C), 8 for high-density lipoprotein cholesterol (HDL-C), and 8 for triglyceride. Serum TC and LDL-C levels were inversely related to AF risk (relative risk [RR] = 0.81, 95% confidence interval [CI]: 0.72-0.92; RR = 0.79, 95% CI: 0.70-0.88, respectively). Likewise, elevated HDL-C levels were associated with a reduced AF risk (RR = 0.86, 95% CI: 0.76-0.97), whereas no significant association was observed between triglyceride levels and incident AF (RR = 1.02, 95% CI: 0.90-1.17).

CONCLUSIONS

Our meta-analysis of large cohort studies found an inverse relationship between serum TC, LDL-C, and HDL-C levels and AF risk, although there was no significant association between TG levels and incident AF. Future studies regarding AF risk stratification may take these blood lipids into consideration, and further efforts are needed to investigate the potential mechanisms.

Upstream therapeutic strategies of valsartan and fluvastatin on hypertensive patients with non-permanent atrial fibrillation

AIM

To investigate the upstream therapeutic effects of fluvastatin and valsartan on hypertensive patients with non-permanent atrial fibrillation (AF).

METHODS

A total of 189 patients who were admitted to outpatient and inpatient department from eight medical centers in China, diagnosed as hypertension with non-permanent AF, were divided into four groups randomly: the CCBs group (group A, n = 45); CCB + fluvastatin group (group B, n = 48); valsartan group (group C, n = 46); valsartan + fluvastatin group (group D, n = 50). The four groups were followed up for 24 months. The blood routine, biochemical examination, echocardiography, high sensitive C-reactive protein (hs-CRP), N-terminal pro-brain natriuretic peptide (NT-proBNP), the maintenance rate of sinus rhythm, and the recurrence of paroxysmal AF or persistent AF incidence were observed in these groups before and after 24 months' treatment.

RESULTS

After 24 months of follow-up, there were 178 cases of patients who have completed the study. (a) There was no significant difference in blood routine, liver, and renal function in each group (P > 0.05). (b) The blood lipids level in groups B and D was significantly reduced after treatment (P < 0.01). There was no significant difference of hs-CRP level in group A (P > 0.05). The left ventricular remodeling was significantly alleviated in group C and group D (P < 0.05). The NT-ProBNP level was significantly decreased in group D (P < 0.05). (c) The sinus rhythm maintenance rate of group B, group C, and group D was higher than group A (77.78%, 70.45%, 79.17% vs 43.90%), the occurrence of persistent AF was significantly lower than group A (11.11%, 14.29%, 8.33% vs 31.71%; P < 0.05).

CONCLUSIONS

CCB plus fluvastatin and valsartan can reduce the recurrence rate of non-permanent AF and to delay the progression from non-permanent AF to permanent AF in patients with hypertension. The combined application of valsartan and fluvastatin is more effective than valsartan or CCB alone in the upstream therapies of AF.