Sacubitril/valsartan may improve sinus rhythm maintenance after ablation in NPAF patients with hypertension

PURPOSE: The efficacy of radiofrequency catheter ablation (RFCA) alone for nonparoxysmal atrial fibrillation (NPAF) is unsatisfactory. This study investigated the effect of sacubitril/valsartan, a type of angiotensin receptor neprilysin inhibitor (ARNI), on NPAF patients with hypertension who underwent RFCA and analysed the possible influencing factors. METHODS: In this prospective, randomized clinical trial, 240 NPAF patients were randomly divided into a control group (n = 121) and an ARNI group (n = 119). The primary outcome was freedom from atrial fibrillation (AF) and atrial tachycardia/atrial flutter (AT/AFL) for ≥ 30 s without antiarrhythmic medications at 15 months after the 3-month blanking period. The secondary outcomes included recurrence types, blood pressure, echocardiographic parameters and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels. RESULTS: At 15 months, a higher maintenance rate of sinus rhythm was achieved in the ARNI group compared to the control group (79.8% vs. 69.4%, hazard ratio [HR] 0.59; 95% confidence interval [CI] 0.36-0.98; P = 0.04). Moreover, a smaller left atrial diameter (adjusted mean difference -1.9 mm [95% CI -3.2 to -0.5], P = 0.02) and lower NT-proBNP level (adjusted median difference -34 pg/ml [95% CI -62 to -6], P = 0.03) were observed in the ARNI group than in the control group at 15 months. Among the patients who recurred, a lower incidence of AF (50.0% vs. 62.2%, P = 0.01) was found in the ARNI group, but presented a significantly higher incidence of AT/AFL. In the subgroup analysis, compared with those in the control group, more patients in the ARNI group achieved success in patients with EF < 50% (93.6% vs. 61.1%, P = 0.01) or low-voltage areas (LVAs) (80.0% vs. 61.3%, P = 0.02). Multivariate Cox regression analysis revealed that ARNI was an independent protective factor against AF or AT/AFL recurrence in patients with EF < 50% or LVAs at 15 months. CONCLUSION: ARNI is effective in NPAF patients with hypertension after RFCA, especially those with EF < 50% or LVAs, which can significantly improve their prognosis.