Amlodipine use in atrial fibrillation
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Amlodipine and Atrial Fibrillation Risk in Hypertensive Patients
Several studies have examined the relationship between amlodipine, a dihydropyridine calcium channel blocker, and the risk or recurrence of atrial fibrillation (AF) in patients with hypertension. Evidence suggests that amlodipine may be associated with a higher prevalence and recurrence of AF compared to other antihypertensive agents, particularly angiotensin II receptor blockers (ARBs) and ACE inhibitors 1239.
Increased Prevalence and Recurrence of AF with Amlodipine
Research shows that hypertensive patients using amlodipine have a higher prevalence of AF than those not using the drug, especially in older patients and those on higher doses for longer periods . In direct comparisons, amlodipine-based therapy resulted in a higher incidence of new-onset and persistent AF than valsartan-based therapy, an ARB, in large clinical trials . Similarly, studies found that amlodipine was less effective than both valsartan and ramipril (an ACE inhibitor) in preventing AF recurrence, even when blood pressure reduction was similar across groups .
Comparative Effectiveness: Amlodipine vs. ARBs and ACE Inhibitors
Multiple studies consistently report that ARBs such as valsartan and losartan, as well as ACE inhibitors like ramipril, are more effective than amlodipine in reducing the risk of AF recurrence in hypertensive patients, including those with diabetes or those already on antiarrhythmic drugs 359. The combination of ARBs with amlodipine may offer additional benefits, as seen in both clinical and animal studies, where such combinations reduced AF duration and improved cardiac and renal function 578.
Amlodipine and Mortality in AF Patients
Long-term follow-up data from large trials indicate that while AF increases the risk of stroke, heart failure, and mortality, patients treated with amlodipine had lower all-cause and non-cardiovascular mortality rates compared to those treated with chlorthalidone, another antihypertensive agent . However, this benefit does not appear to extend to AF prevention itself.
Effects on Endothelial Function and Inflammation
Both amlodipine and valsartan improve endothelial function and reduce inflammation in hypertensive patients with AF, but valsartan has a significantly greater effect on these parameters. This may be important for stroke prevention in elderly patients with AF .
Timing of Amlodipine Administration
The timing of amlodipine administration (morning vs. bedtime) in combination with ARBs does not significantly affect blood pressure control or variability in patients with paroxysmal AF, though some markers of cardiac stress may improve with bedtime dosing .
Conclusion
Amlodipine is effective for blood pressure control in hypertensive patients, but evidence suggests it may be associated with a higher risk of AF onset and recurrence compared to ARBs and ACE inhibitors. Combining amlodipine with ARBs may help reduce AF risk, but ARBs alone or in combination appear to offer superior protection against AF recurrence and may provide additional benefits for endothelial function and inflammation. For hypertensive patients at risk of AF, ARBs or ACE inhibitors may be preferred over amlodipine for arrhythmia prevention.
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