Association of Antihypertensive Combinations with Cardiovascular Outcomes in Patients with Atrial Fibrillation Open Access

Ganesh, Nimisha (Spring 2021)

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Objective: Hypertension remains the most important manageable predisposing risk factor for atrial fibrillation (AF) [1]. The study focuses on the comparative outcomes of different antihypertensive therapy combinations in AF patients. The specific aims of the analysis were: 1) to evaluate the risk of myocardial infarction, heart failure and stroke outcomes in AF patients by type of antihypertensive therapy; 2) to determine if sex influences the association of antihypertensive treatments with outcomes in patients with AF.

Methods: This analysis used the MarketScan Commercial and the MarketScan Medicare Supplemental Databases (Truven Health Analytics) to identify patients with nonvalvular AF who were prescribed with antihypertensives. We selected 970,428 patients who had at least one antihypertensive medication prescription after their date of diagnosis of non-valvular AF. Cox proportional hazards models were used to determine the association between antihypertensive treatments and the time until outcome. Follow-up started at the date of the first prescription of antihypertensive medication after the diagnosis of AF and continued until a hospitalization for the outcome of interest (myocardial infarction, heart failure, stroke), September 30, 2015, or patient health plan disenrollment, whichever occurred first.

Results: Among 970,428 eligible AF patients, there were 12,441 myocardial infarctions, 49,308 heart failures, and 17,250 strokes. The incidence of heart failure was generally higher when compared to myocardial infarction and stroke in the study population. Compared to patients prescribed with beta blockers the incidence rates and hazard ratios (HR) for myocardial infarction, heart failure and stroke were the highest in patients prescribed with 4 or more antihypertensives (HR 3.66, 95%CI 3.30-4.05 for myocardial infarction, HR 12.81, 95%CI 11.63-14.11 for heart failure and HR 1.52, 95% CI 1.42-1.63 for stroke). Men presented increased risk for stroke compared to women, for all categories of hypertension management. Risk for heart failure was higher in men when compared to women for all categories except triple therapy combinations (other than angiotensin converting enzyme inhibitors/beta blockers/diuretic or angiotensin receptor blockers/beta blockers/diuretic).

Conclusions: The analysis identified higher risk of most outcomes among patients taking multiple antihypertensive medications, which could be explained by higher severity of underlying hypertension in that group. We could not identify the most effective hypertension management strategy; however, our findings corroborate the relevance of hypertension as a risk factor for adverse outcomes in AF patients and the importance of optimizing strategies for hypertension management in these patients. 

Table of Contents

1.    Introduction

1.1. Hypertension and Atrial Fibrillation

1.2  Epidemiology

1.3  Pathogenesis

1.4  Management of Arrhythmias in Patients with Hypertension

1.5  Public Health Implications

2.    Methods

2.1  Study Population

2.2  Specific Aims

2.3  Definition of the Exposure

2.4  Identification of Prespecified Covariates

2.5  Endpoints

2.6  Statistical Analysis

3.    Results

3.1  Patient Characteristics

3.2  Incidence Rates

3.3  Myocardial Infarction

3.4  Heart Failure

3.5  Stroke

3.6  Interaction with Sex

4.    Discussion

5.    Strengths and Limitations

6.    Conclusions

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