Effect of antihypertensive agents on the risk of new-onset and recurrent atrial fibrillation: a Bayesian network meta-analysis of randomized controlled trials

Abstract Aims The comparative effectiveness of specific antihypertensive agents in preventing new-onset or recurrent atrial fibrillation (AF) remains under debate. This study aimed to evaluate the impact of different antihypertensive agents on AF risk. Methods and results Medline, Cochrane, EMBASE, and ClinicalTrials.gov databases were searched for randomized controlled trials (RCTs) reporting AF events as a predefined outcome. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), dihydropyridine calcium channel blockers (CCBs), β-blockers, mineralocorticoid antagonists (MRAs), and thiazide diuretics (TDs) were analyzed. The risk ratio (RR) with a 95% credible interval (CrI) was calculated within a Bayesian random-effects network meta-analysis (NMA). Treatments were ranked using the surface under the cumulative ranking (SUCRA). Twenty-two RCTs randomising 66,156 patients with hypertension, diabetes, or AF were included. ACE inhibitors plus TD (RR 0.44; 95% CrI 0.23–0.82), ACE inhibitors (RR 0.66; 95% CrI 0.44–0.95), and ARBs (RR 0.52; 95% CrI 0.38–0.70) were associated with lower rates of new-onset or recurrent AF compared with CCBs. SUCRA ranked ACE inhibitors plus TD (0.86) as the best, followed by ARBs (0.77), MRAs (0.75), and ACE inhibitors (0.53) for preventing AF events. These findings were consistent across secondary and sensitivity analyses. Conclusion In this NMA comparing multiple antihypertensive regimens in patients with hypertension, diabetes, or AF, ACE inhibitors plus TD, ACE inhibitors, and ARBs were the most effective in reducing AF events, outperforming CCBs. Registration PROSPERO Database (CRD42024588765).