The role of the renin–angiotensin system in atrial fibrillation and the therapeutic effects of ACE‐Is and ARBS

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • Atrial fibrillation (AF) is the most common rhythm disturbance in medical practice. • AF can be managed with the prevention of thromboembolism and either a rate control or rhythm control strategy; however, as both treatment strategies have important limitations, a preventative strategy could be a more attractive option. • Angiotensin‐converting enzyme inhibitors (ACE‐Is) and angiotensin‐II receptor blockers (ARBs) may play a role in preventing AF recurrence. WHAT THIS STUDY ADDS • The aim of the present review was to analyse evidence supporting the usefulness of renin–angiotensin system (RAS) inhibition in patients with AF and to focus on which specific subset of patients it most favours. • Although many studies and meta‐analysis have supported the advantage of RAS block in preventing AF recurrence, it is not possible to recommend the use of ACE‐Is and ARBs in routine clinical practice specifically to prevent AF. • As these drugs are safe and manageable, they should be considered the drugs of choice in patients with AF and coexisting clinical conditions such as hypertension, coronary disease, heart failure and diabetes mellitus. Atrial fibrillation (AF) is the most common rhythm disturbance in medical practice and represents a very expensive health problem. AF can be managed with the prevention of thromboembolism and either a rate control or rhythm control strategy. As both strategies have important limitations, probably a preventative strategy in patients at risk of developing arrhythmia can be a more attractive option. The renin–angiotensin system (RAS) seems to be involved in the genesis of arrhythmia by the following two mechanisms: the induction of atrial fibrosis and structural remodelling by mitogen‐activated protein kinase (MAPK) expression and reduction of collagenase activity; the induction of electrical remodelling by shortening of the atrial effective refractory period (AERP) and of the action potential duration. For these reasons it has been hypothesized that angiotensin‐converting enzyme inhibitors (ACE‐Is) and angiotensin‐II receptor blockers (ARBs) may play a role in preventing AF recurrence. The aim of the present review was to analyse evidence supporting the usefulness of RAS inhibition in patients with AF in order to focus on which specific subset of patients it would most favour. After reviewing the literature, we conclude that, although many studies and meta‐analyses have supported the advantage of RAS block in preventing AF recurrence, it is premature to recommend the use of ACE‐Is and ARBs specifically for the prevention of AF. However we believe that as these drugs are safe and manageable, they should be considered the drugs of choice in patients with AF and coexisting clinical conditions such as hypertension, coronary disease, heart failure and diabetes mellitus.