Aldosterone Antagonists in the Prevention of Atrial Fibrillation in Adult Patients with Congestive Heart Failure: A Meta-analysis of Randomized Controlled Trials

BACKGROUND: Onset of atrial fibrillation (AF) is related to congestive heart failure (CHF) severity. The renin angiotensin-aldosterone system activates the mineralcorticoid receptor in patients with CHF, increasing the concentration of aldosterone and cortisol levels. Prolonged, these may cause deleterious effects leading to arrhythmia, worsening of CHF and mortality. Aldosterone antagonists may influence the atrial fibrosis and remodeling, which may prevent the onset of AF in patients with CHF. METHODS: Randomized, double-blind trials were searched from PUBMED, Medline, Embase and Cochrane on the effect of aldosterone antagonists (i.e., spironolactone, eplerenone, or canrenone) vs placebo on the prevention of AF, worsening CHF and deaths from cardiovascular causes. Selected studies were subjected to meta-analysis on the effects on incidence of new-onset AF, death from cardiovascular causes, hospitalization from CHF, and hypokalemia. RESULTS: Four randomized trials were selected, for a total of 5,114 patients were identified and extracted. Aldosterone antagonists reduced the incidence of new-onset AF by 42% (relative risk RR 0.58; 95% CI 0.40, 0.85; p=0.005) vs placebo. Mortality from cardiovascular causes was reduced by 21% (RR 0.79; 95% CI 0.65, 0.96; p=0.002). The risk of hospitalization from CHF was reduced by 37% (RR 0.63; 95% CI 0.53, 0.76; p=0.00001). CONCLUSION: The additional of aldosterone antagonists to the treatment of CHF significantly reduced the risk of new-onset AF, hospitalization from CHF, and deaths from cardiovascular causes.