Sacubitril/valsartan equals enalapril, valsartan alone for preventing AF in HF

Sacubitril/valsartan performs comparably as enalapril or valsartan alone in preventing atrial fibrillation (AF) occurrence in patients with heart failure (HF), reports a recent meta-analysis.

Drawing from the online databases of Embase and PubMed, the researchers retrieved six eligible double-blinded randomized controlled trials that tested sacubitril/valsartan in a cumulative sample of 7,750 HF patients; a parallel group of 7,762 controls had been assigned to receive active controls. The outcome of interest was AF during follow-up.

Overall, 694 patients in the sacubitril/valsartan group developed AF, as opposed to 650 in the active control arm. The resulting incidence rates were 9.0 percent and 8.4 percent, respectively. Random-effects modelling found no significant risk elevation relative to controls (relative risk [RR], 1.07, 95 percent confidence interval [CI], 0.95–1.9; p=0.26). Heterogeneity of evidence was small.

Three trials also reported atrial flutters arising during follow-up. In total, 44 and 42 patients in the sacubitril/valsartan and active control groups developed atrial flutter, yielding incidence rates of 0.6 percent for both. Pooled occurrence of atrial flutter did not differ significantly according to treatment (RR, 1.01, 95 percent CI, 0.55–1.86).

The present meta-analysis had notable limitations that need to be taken into consideration, the researchers said. “First, AF was not a prespecified endpoint in all included trials. The definition of AF and the methods used to document AF were not reported. The AF occurrence was calculated by reported adverse events. It is difficult to exclude the fact that some of the patients had asymptomatic AF that converted spontaneously.”

Moreover, the included studies had differences in terms of population characteristics, study design, and active controls used, and all were sponsored by a single pharmaceutical company, which may have introduced a high risk of bias.