Electrophysiology Enalapril treatment and hospitalization with atrial tachyarrhythmias in patients with left ventricular dysfunction Alawi A. Alsheikh-Ali, MD, a Paul J. Wang, MD, b William Rand, PhD, c Marvin A. Konstam, MD, a Munther K. Homoud, MD, a Mark S. Link, MD, a N. A. Mark Estes III, MD, a Deeb N. Salem, MD, a and Amin M. Al-Ahmad, MD b Boston, Mass, and Stanford, Calif Background Experimental and clinical evidence suggests a preventive role for agiotensin-coverting enzyme (ACE) inhibitors on the development of atrial fibrillation. However, the effect of ACE inhibition on hospitalization with atrial tachyarrhythmias in patients with left ventricular (LV) dysfunction is not known. We sought to determine whether enalapril treatment reduced hospitalizations with atrial tachyarrhythmias in patients with LV dysfunction. Methods We performed a retrospective analysis of the Studies of Left Ventricular Dysfunction (SOLVD) trial. Hospital- izations with atrial tachyarrhythmias were noted. Results A total of 192 hospitalizations with atrial tachyarrhythmias occurred in 158 patients during a follow-up pe- riod of 34 months. The time to first hospitalization with atrial tachyarrhythmias or death was significantly lower in the ena- lapril group (P = .005). In a multivariate analysis adjusting for the presence of atrial fibrillation at study entry, enalapril treatment was associated with a reduction in the rate of hospitalization with atrial tachyarrhythmias or death (RR, 0.87; 95% CI, 0.79 – 0.96; P = .007). The incidence of hospitalization with atrial tachyarrhythmias was 7.9 hospitalizations per 1000 patient-years of follow-up in the enalapril group, compared with 12.4 per 1000 patient-years in the placebo group (RR, 0.64; 95% CI, 0.48 – 0.85; P = .002). Conclusion Enalapril is associated with a decreased incidence of hospitalization with atrial tachyarrhythmias in patients with LV dysfunction. (Am Heart J 2004;147:1061–5.) See related Editorial on page 953. Atrial fibrillation (AF) is a growing public health con- cern, with AF being the most common chronic ar- rhythmia encountered in clinical practice. 1 The preva- lence of atrial fibrillation in patients with heart failure ranges from 10% to 30% and has been associated with increased mortality rates. 2,3 In a canine model of heart failure, angiotensin-converting enzyme (ACE) inhibition has been shown to decrease the extent of atrial fibro- sis, reduce conduction abnormalities, and decrease AF duration. 4,5 To date, 2 studies have demonstrated a decreased incidence of AF in patients with left ventric- ular dysfunction who were treated with ACE inhibi- tors. 6,7 However, both analyses were limited to electro- cardiographic evidence of AF. Whether the observed benefit of ACE inhibitors extends to hospitalizations with atrial tachyarrhythmias is not known. Therefore, we tested the hypothesis that the inci- dence of hospitalization with atrial tachyarrhythmias was reduced by enalapril treatment in patients with LV dysfunction who were enrolled in the Studies of Left Ventricular Dysfunction (SOLVD) trials. Methods Patients The SOLVD trails were a pair of concurrent randomized, double-blind, placebo controlled trials of patients with symp- tomatic and asymptomatic left ventricular dysfunction. 8,9 Pa- tients who had a left ventricular ejection fraction 0.35 were randomized to receive treatment with enalapril or placebo. From the a Tufts-New England Medical Center, Department of Medicine, Division of Cardiolgy, Boston, Mass, b Electrophysiology/Arrhythmia Service, Cardiovascular Medicine Division, Stanford University School of Medicine, Stanford, Calif, and c De- partment of Community Medicine, Tufts University School of Medicine, Boston, Mass. Submitted July 18, 2003; accepted December 11, 2003. Reprint requests: Amin Al-Ahmad, MD, Electrophysiology/Arrhythmia Service, Cardio- vascular Medicine Division, Stanford University School of Medicine, 300 Pasteur Dr, H-2146 , Stanford, CA 94305-5233. E-mail: aalahmad@cvmed.stanford.edu 0002-8703/$ - see front matter © 2004, Elsevier Inc. All rights reserved. doi:10.1016/j.ahj.2003.12.033