| Objective:Atrial fibrillation (AF) is frequently encountered in patients with heart failure (HF) and is also a predictor of morbidity and mortality in this population. Experimental and small patient studies have demonstrated that blocking the renin-angiotensin-aldosterone system may prevent AF. Recent experimental studies have shown electrical and structural atrial remodeling with increased fibrosis in animals with HF and have suggested a preventive effect of ACE inhibitors (ACEI) on the development of AF. We analyzed the patients with heart failure(HF) in hospitalization in recent four years, both retrospective and follow-up measures were done in our study to evaluate the effect of angiotensin converting enzyme inhibitors (ACEI) on prevention the development of atrial fibrillation (AF) in this population.Method:Hospitalized patients with heart failure from cardio department of the Second Hospital of Tianjin Medical University were enrolled. The cases we collected contained complete history from Jan 2006 to Apr 2009.Basci clinical features, patient history,treatment and a part of clinical biochemical indicators of laboratory examinations were clearly recorded. All of the patients we collected were following up,1016 cases were completed.we divided them into two groups:ACEI group and the control group.The incidence rate of AF were measured in our following-up. Single factor analysis and multivariate COX model were applied to analyze the association between ACEI and the incidence of AF by using SPSS 17.0 software.Results:1. grouping:ACEI and the control group1.1 compare the baseline patient characteristics in the two groups Men in ACEI group were more than the control group(53.9vs42.9, p=0.000), patients taking ACEI had a higher prevalence of myocardial infarction; digitalis(12.9vs8.5, p=0.025), vasodilators(87.5vs80.6, p=0.003), aspirin(94.3vs88.7, p=0.001)were more used in ACEI group; with left atrium diameter larger (38.0±6.0vs36.9±5.9,p=0.004) and aldosterone level lower (87.88±38.00vs93.36±41.07, p=0.027) than the control group. There was no statistical difference about other factors between the two groups(p>0.05).1.2compare the incidence rate of AF between the two groups For 2.4±0.9 years,250 cases of the one thousand and sixteen patients developed AF during our following-up,83 cases(16.2%) in the ACEI group and 167 cases(33.1%)in the control group(p=0.000), the incidence of AF in the ACEI group was significantly less than the control group(p=0.000).1.3 Kaplan-Meier curves for time to occurrence of AF During follow-up, the probability of remaining in sinus rhythm was significantly higher in ACEI group than in the control group (p=0.000). The beneficial effect of ACEI on the development of AF become more marked during our follow-up.2.according to whether patients develop AF during our follow-up we divided them into AF group and NO-AF group.2.1 the baseline patient characteristics in the two groups(1)The proportion of left ventricular hypertrophy (36.0vs23.9), hospitalization for HF (20.8vs3.8), myocardial infarction (53.6vs25.2), diabetes mellitus (39.2vs27.7) and the usage of spironolactone (28.8vs7.8), digitalis (28.0vs5.1),calcium-channel blockers (50.0vs42.7) was higher in AF group (P<0.05).(2) The patients who developed AF were older(67.81±8.37vs65.54±9.26), have larger left atrium diameter(43.47±5.62vs35.48±4.63), and, more often, they have higher blood urea nitrogen(6.98±6.25vs5.79±2.12), creatinine (86.30±27.23vs79.12±22.70) and uric acid level(352.47±113.79vs316.03±90.92) (P＜0.05).(3)The proportion of PCI (24.4vs31.5)and ACEI(33.2vs56.0) therapy was lower in AF group (P＜0.05).(4) The serum sodium (140.72±5.09vs142.11±6.98), serum chlorine (103.77±5.25vs104.83±4.07) level and EF (36.88±12.06vs47.48±7.67) were lower in AF group (P<0.05).(5)There was lower proportion of patients with NYHA classⅡsymptoms(51.6vs83.3) in AF group, while, the proportion of patients with NYHA class III(34.4vs15.0) and IV(14.0vs1.7) symptoms was higher(P<0.05).(6) There was no statistical difference about other factors between the two groups (p>0.05).2.2 Single factor COX model applied to analyze the development of AF(1) Age(OR1.022, P=0.003), LVH(OR2.314, P=0.000), LA(OR1.213, P=0.000), hospitalization for HF(OR1.342, P=0.000), myocardial infarction(OR2.148, P=0.000), diabetes mellitus(OR1.369, P=0.001), spironolactone(OR1.182, P=0.000), blood urea nitrogen(OR1.047, P=0.000), creatinine(OR 1.009, P=0.000), uric acid(OR1.003, P=0.000) and aldosterone level(OR1.003, P=0.045) were the risk factors of AF.(2)ACEI(OR0.109, P=0.000),EF(OR0.937, P=0.000), digitalis(OR0.471, P=0.000), serum sodium(OR0.952, P=0.000) and serum chlorine level (OR0.949, P=0.000)were predictors for reduction in the incidence of AF.(3) In our study, we have a definition:NYHA classⅡsymptom was mild heart failure, NYHA classⅢandⅣwere severe. The proportion of patients with severe heart failure was higher in AF group(48.4vs16.7, p=0.000). Single factor analysis show: heart failure was the risk factor of AF(OR1.972, P=0.000).(4)Compare with the baseline, as time went on, the effect of PCI and CCB was gradually vanished. While aldosterone level had a trend to increase the risk of the development of AF(OR1.003, p=0.045).2.3 multivariate COX model applied to analyze the development of AF Cox proportional-hazard models were performed for each variable with treatment forced in all models. Variables with a probability value (P<0.05) were included in a multivariate Cox proportional hazard model. The result show:ACEI was the most powerful predictor for risk reduction of AF(OR0.044, P=0.000),EF also have the effect to prevent the development of AF(OR0.925, P=0.000).Heart failure(OR1.896, P=0.000), left ventricular hypertrophy(OR2.362, P=0.001), left atrium diameter (OR1.446, P=0.000), myocardial infarction(OR2.053, P=0.006) were the independent risk factors of AF.Conclusions:1. ACEI has the effect to prevent the development of AF in patients with heart failure.2. The longer we followed up, the beneficial effect of ACEI was more significant in patients with heart failure.3. ACEI and EF were the independent protective factors of AF, ACEI was the most powerful predictor for risk reduction of AF.4. Heart failure, left ventricular hypertrophy, left atrium diameter, myocardial infarction were the independent risk factors of AF.5. There was direct ratio between AF and the degree of HF. |
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