Upstream therapy, what's new?

Authors: R. Lábrová
Authors‘ workplace: Interní kardiologická klinika LF MU a FN Brno
Published in: Kardiol Rev Int Med 2017, 19(4): 231-236


Atrial fibrillation (AF) is the most common arrhythmia and is associated with high morbidity and mortality and poor quality of life. Remodelling of the atrial substrate begins long before the first episode of AF and continues to progress. AF can maintain and further deepen most of the mechanisms of remodelling and hypercoagulability, which makes it progressive in itself. Upstream therapy reduces the progression of remodelling or induces positive remodelling of the atrium, thus preventing AF or improving sinus rhythm maintenance. In patients without history of AF who have heart failure with reduced left ventricular function and/or have hypertension or possibly left ventricular hypertrophy are indicated for the primary prevention of AF by the use of renin-angiotensin-aldosterone system blockers (ACE-I or sartans). Treatment with RAAS antagonists is indicated for these diagnoses as well as for secondary prevention. Patients with recurrent AF in antiarrhythmic therapy undergoing electrical cardioversion may be pre-treated with ACE-I or sartans. In patients without structural heart disease, this ACE-I or sartan treatment is not indicated in primary or secondary prevention. Based on the results of the RACE 3 study, upstream therapy in secondary prevention in patients undergoing cardioversion, maximum tolerated doses of RAAS blockers, statins, weight reduction diet, rehabilitation and psychological education for patient collaboration are recommended. Accentuated upstream therapy leads to a sustained sinus rhythm after 1 year of follow-up in 75% of patients as compared to 63% achieved with conventional therapy.

Key words:
atrial remodelling – atrial fibrillation – rhythm control – upstream therapy – renin-angiotensin-aldosterone system blockers – angiotension-converting enzyme inhibitors – angiotensin receptor blockers – primary and secondary prevention


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