急性心肌梗死并左室功能不全者心房纤颤的预后风险:OPTIMAAL的经验

Aims The present study aimed to determine the frequency and the impact on clinical outcome of atrial fibrillation(AF) in patients with acute myocardial infarction(AMI) and left ventricular dysfunction. Methods and results In the OPTIMAAL trial, 5477 patients with AMI and signs of left ventricular dysfunction were included. At baseline, 655 patients(12% ) had AF, and 345(7.2% ) developed new- onset AF during follow- up(2.7± 0.9 years). Older patients, patients with history of angina and worse Killip class had and developed AF more frequently(P< 0.001). Patients with AF at baseline were at increased risk relative to those without AF for mortality[adjusted hazard ratio(HR) of 1.32, P=0.001] and for stroke(HR 1.77, P< 0.001). New- onset AF was associated with increased subsequent mortality for the first 30 days following randomization(HR 3.83, P< 0.001) and the entire trial period(HR 1.82, P< 0.001). Risk of stroke was increased for the first 30 days(HR 14.6, P< 0.001) and for the whole trial period(HR 2.29, P< 0.001). Conclusion AF is frequently observed in patients with AMI complicated by heart failure. Current AF, and the development of new AF soon after AMI, is associated with increased risk of death and stroke.

与阿替洛尔相比血管紧张素Ⅱ受体阻断剂降低新发心房纤颤和继发脑卒中:LIFE研究

Objectives: This study was designed to evaluate whether different antihypertensive treatment regimens with similar blood pressure reduction have different effects on new- onset atrial fibrillation(AF). Background: It is unknown whether angiotensin II receptor blockade is better than beta- blockade in preventing new- onset AF. Methods: In the Losartan Intervention For Endpoint reduction in hypertension(LIFE) study 9,193 hypertensive patients and patients with electrocardiogram documented left ventricular hypertrophy were randomized to once- daily losartan or atenolol- based antihypertensive therapy. Electrocardiograms were Minnesota coded centrally, and 8,851 patients without AF by electrocardiogram or history, who were thus at risk of developing AF, were followed for 4.8± 1.0 years. Results: New- onset AF occurred in 150 patients randomized to losartan versus 221 to atenolol(6.8 vs. 10.1 per 1,000 person- years; relative risk 0.67, 95% confidence interval[CI] 0.55 to 0.83, p< 0.001), despite similar blood pressure reduction. Patients receiving losartan tended to stay in sinus rhythm longer(1,809± 225 vs. 1,709± 254 days from baseline, p=0.057) than those receiving atenolol. Moreover, patients with new- onset AF had two- , three- and five- fold increased rates, respectively, of cardiovascular events, stroke, and hospitalization for heart failure. There were fewer composite end points(n=31 vs. 51, hazard ratio=0.60, 95% CI 0.38 to 0.94, p=0.03) and strokes(n=19 vs. 38, hazard ratio=0.49, 95% CI 0.29 to 0.86, p=0.01) in patients who developed new- onset AF in the losartan compared to the atenolol treatment arm of the study. Furthermore, Cox regression analysis showed that losartan(21% risk reduction) and new- onset AF both independently predicted stroke even when adjusting for traditional risk factors. Conclusions: Our novel finding is that new- onset AF and associated stroke were significantly reduced by losartan compared to atenolol- based antihypertensive treatment with similar blood pressure reduction.

有心房纤颤病史的高血压患者的心血管发病率和死亡率:LIFE研究(洛沙坦干预降低高血压患者终点事件研究)

Objectives: We assessed the impact of antihypertensive treatment in hypertensive patients with electrocardiographic(ECG) left ventricular(LV) hypertrophy and a history of atrial fibrillation(AF). Background: Optimal treatment of hypertensive patients with AF to reduce the risk of cardiovascular morbidity and mortality remains unclear. Methods: As part of the Losartan Intervention For End point reduction in hypertension(LIFE) study, 342 hypertensive patients with AF and LV hypertrophy were assigned to losartan or atenolol- based therapy for 1,471 patient- years of follow- up. Results: The primary composite end point(cardiovascular mortality, stroke, and myocardial infarction) occurred in 36 patients in the losartan group versus 67 in the atenolol group(hazard ratio[HR]=0.58, 95% confidence interval[CI] 0.39 to 0.88, p=0.009). Cardiovascular deaths occurred in 20 versus 38 patients in the losartan and atenolol groups, respectively(HR=0.58, 95% CI 0.33 to 0.99, p=0.048). Stroke occurred in 18 versus 38 patients(HR=0.55, 95% CI 0.31 to 0.97, p=0.039), and myocardial infarction in 11 versus 8 patients(p=NS). Losartan- based treatment led to trends toward lower all- cause mortality(30 vs. 49, HR=0.67, 95% CI 0.42 to 1.06, p=0.090) and fewer pacemaker implantations(5 vs. 15, p=0.065), whereas hospitalization for heart failure took place in 15 versus 26 patients and sudden cardiac death in 9 versus 17, respectively(both p=NS). The benefit of losartan was greater in patients with AF than those with sinus rhythm for the primary composite end point(p=0.019) and cardiovascular mortality(p=0.039). Conclusions: Losartan is more effective than atenolol- based therapy in reducing the risk of the primary composite end point of cardiovascular morbidity and mortality as well as stroke and cardiovascular death in hypertensive patients with ECG LV hypertrophy and AF.