Atrial Fibrillation and Hyperaldosteronism

Relationship between the Renin-Angiotensin-Aldosterone System and Atrial Fibrillation

The American College of Cardiology notes that stimulation of the renin-angiotensin-aldosterone system (RAAS) promotes structural and electrophysiological effects in the atria that increase susceptibility to arrhythmias, including atrial fibrillation, in patients with hypertension 1, 2
The European Heart Journal reports that components of the RAAS, including angiotensin II, angiotensin-converting enzyme, and aldosterone, are synthesized locally in the atrial myocardium and increase during atrial tachycardia and atrial fibrillation, with a moderate level of evidence 1
The activation of the RAAS is strongly implicated in the development of atrial fibrillation through multiple mechanisms, with a high level of evidence 3

The European Heart Journal states that angiotensin II promotes fibrosis through AT1 receptors, increasing the synthesis of TGF-beta1 in the atria and ventricles, as well as the release of growth factors and inflammatory mediators such as IL-6, in patients with heart failure, with a high level of evidence 3, 4
The resulting structural remodeling causes interruption of myocardial cell bundles and heterogeneity in intra-atrial conduction, creating a substrate for multiple re-entry circuits that help perpetuate atrial fibrillation, with a moderate level of evidence 3, 4
The oxidative stress and inflammation induced by aldosterone are an additional effect of the RAAS that favors atrial structural and electrical remodeling, with a low level of evidence 3

The American College of Cardiology notes that in patients with primary hyperaldosteronism, the incidence of atrial fibrillation is significantly increased, with a high level of evidence 1, 5

The American College of Cardiology reports that in experimental models of heart failure, spironolactone and eplerenone decreased atrial fibrosis and/or susceptibility to atrial fibrillation, with a moderate level of evidence 1, 5
Treatment with eplerenone is associated with a decrease in atrial fibrillation in patients with heart failure, with a high level of evidence 1, 5

The American College of Cardiology and the European Heart Journal suggest that inhibitors of the angiotensin-converting enzyme or antagonists of angiotensin II receptors may reduce the occurrence of atrial fibrillation in patients with hypertension or left ventricular dysfunction, with a moderate level of evidence 1, 3

The European Society of Hypertension (ESH) and European Society of Cardiology (ESC) guidelines indicate that angiotensin receptor blockers (ARBs) like telmisartan may actually reduce the incidence of new atrial fibrillation, particularly in hypertensive patients 6, 7
Post-hoc analyses have shown less incidence of new atrial fibrillation with angiotensin receptor antagonists, making these agents potentially preferable for hypertensive patients at risk of developing AF 8

The ESH/ESC guidelines suggest that ARBs may be preferred in patients with previous episodes of atrial fibrillation who require antihypertensive therapy 6

While telmisartan is listed in a table of medications linked to drug-induced photosensitivity, there is no evidence in the literature linking telmisartan to an increased risk of atrial fibrillation 9
Drug-induced atrial fibrillation (DIAF) is recognized as an adverse effect of various medications, but ARBs including telmisartan are not listed among the common culprits 10