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Influence of Prevalent and Incident Atrial Fibrillation on Post-Trial Major Events in ALLHAT
L Julian Haywood1, Barry R Davis2, Linda B Piller2
1LAC+USC Medical Center, Keck School of Medicine, Los Angeles, CA, USA.
Insights
Atrial fibrillation/flutter (AF/AFL) significantly increased mortality risk in hypertensive patients during and after the ALLHAT trial. Amlodipine and pravastatin treatments showed improved survival outcomes compared to other interventions.
Area of Science:
- Cardiovascular Medicine
- Clinical Trials
- Pharmacotherapy
Background:
- Atrial fibrillation/flutter (AF/AFL) is a known risk factor for adverse cardiovascular events.
- Limited data exists on the long-term impact of antihypertensive and lipid-lowering therapies in hypertensive patients with AF/AFL.
Purpose of the Study:
- To evaluate the continued impact of AF/AFL on patient outcomes during post-trial follow-up.
- To compare the long-term effects of amlodipine, chlorthalidone, lisinopril, and pravastatin in hypertensive patients with and without AF/AFL.
Main Methods:
- Utilized data from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).
- Conducted post-hoc analyses using administrative databases for post-trial outcomes.
- Compared outcomes of patients with AF/AFL to those without, stratified by randomized treatment groups.
Main Results:
- Patients with AF/AFL experienced significantly higher all-cause mortality during the trial and post-trial follow-up.
- Amlodipine treatment was associated with lower 10-year all-cause mortality compared to chlorthalidone in patients with AF/AFL.
- Pravastatin treatment demonstrated lower non-cardiovascular mortality compared to usual care in patients with AF/AFL.
Conclusions:
- AF/AFL confers a sustained increased risk of mortality in hypertensive patients.
- Amlodipine and pravastatin interventions within the ALLHAT trial showed benefits in reducing mortality in patients with AF/AFL.
Aims:
Limited information is available on long-term antihypertensive and lipid-lowering therapy effects on hypertensive patients with atrial fibrillation/flutter (AF/AFL) compared to those without. AF/AFL at baseline or during the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) (mean follow-up 4.9 years) markedly increased risk of stroke, heart failure, CHD, and all-cause mortality. We aimed to determine if AF/AFL continued to impact outcomes during post-trial follow-up (mean 3.8 years).
Methods:
Patients were randomized to chlorthalidone, amlodipine, or lisinopril, and to pravastatin vs. usual care in the lipid-lowering trial (LLT). Of 31,473 available subjects, AF/AFL occurred in 854; 383/14,371 chlorthalidone (2.7%), 247/8565 amlodipine (2.9%), and 224/8537 lisinopril (2.6%). Post-hoc analyses utilized administrative databases for post-trial data. Individuals with AF/AFL were compared to those without during post-trial. Outcomes were analyzed by treatment groups for the antihypertensive and LLT trials.
Results:
Among 854 AF/AFL participants, 491 (57.5%) died: 220 in-trial, 271 post-trial. Ten-year all-cause mortality rates for those with in-trial AF/AFL were similar for chlorthalidone and lisinopril, but lower for amlodipine (68, 66, and 49 per 100 persons, respectively); adjusted HR for amlodipine vs. chlorthalidone was 0.68 (95% CI, 0.54-0.87). Ten-year all-cause mortality rates were 57 vs. 65 per 100 persons (pravastatin vs. usual care); non-CVD mortality rates, 18 vs. 39 per 100 persons (pravastatin vs. usual care) (adjusted HR = 0.46, 95% CI, 0.24-0.86).
Conclusion:
Post-trial follow-up revealed continued deleterious AF/AFL effects. The amlodipine (ALLHAT) and pravastatin (ALLHAT-LLT) treatment groups showed lower all-cause and non-CVD mortality compared to the chlorthalidone and usual-care groups, respectively.
