Mineralocorticoid receptor antagonists reduce new-onset atrial fibrillation across the cardio-kidney-metabolic spectrum: a meta-analysis of randomized clinical trials

Aims Atrial fibrillation is a prevalent arrhythmia among patients with cardio-kidney-metabolic (CKM) diseases and is associated with worse cardiorenal outcomes. Mineralocorticoid receptor antagonists (MRAs) may reduce the incidence and burden of atrial fibrillation, but their effects across CKM populations require further investigation. Methods Random-effects meta-analysis of placebo-controlled randomized clinical trials (RCTs) evaluating the effect of MRAs on the occurrence of new-onset atrial fibrillation/flutter. Hazard ratios and 95% confidence intervals (95%CI) for new-onset atrial fibrillation during follow-up, comparing MRAs to placebo, were collected from individual trials. Results Data from six major RCTs were analyzed, including over 19,500 patients without baseline atrial fibrillation/flutter. Overall, MRAs, compared with placebo, reduced the occurrence of new-onset atrial fibrillation by 21% (HR 0.79, 95% CI 0.65-0.95; p=0.01). Moderate heterogeneity was observed across trials (I2 =36%; Cochran's Q=8.08, p=0.15). Conclusion This meta-analysis suggests that MRAs reduce the risk of new-onset atrial fibrillation across CKM populations.