Prevention of Atrial Fibrillation by Inhibition Conversion Enzyme (ICE) After Radiofrequency Ablation of Atrial Flutter
Ministry of Health, France
CHU de Saint-Etienne

      Atrial Flutter [AFL] is a relatively frequent arrhythmia, considered as benign, but
      associated with both invalidating symptoms and thromboembolic risk. The objective of the
      treatment consists to on the one hand the sinus rhythm [SR] restoration and on the other hand
      the prevention of the long-term recurrence. In this clinical setting, AFL radiofrequency
      ablation [RFA] became the first line therapy due to its both high effectiveness and safety.
      The effectiveness of AFL RFA is attenuated by the subsequent risk of atrial fibrillation
      [AFib] close to 25% at 1 year. This risk of subsequent AFib is related to the common
      substrate between both arrhythmias.

      When AFib occurs, the interest to maintain the SR is still required, even if recent studies
      did not show a significant difference in term of total mortality between rate or rhythm
      control strategies [AFFIRM, RACE and PIAF studies]. The studies published underlined the
      anti-arrhythmic drugs limits in patients with both arrhythmias [AFib and AFL]. After years
      centered on the mechanisms and the electric treatments of AFib, researchers are nowadays
      focusing on the study's evaluation of the atrial tissue substrate.

      Accordingly, the renin-angiotensin system role was investigated in many works. Indeed,
      angiotensin II plays a role in the modification of atrial pressure and in the fibers
      stretching ["stretch"], conditions required for the development of AFib. Angiotensin II is
      also a factor implied in the tissue fibrosis leading to tissue proliferation and collagen
      alteration. These mechanisms lead to atria cells conduction disorders and refractory periods
      modification. Moreover, the enzyme of conversion expression and the angiotensin II receptors
      deterioration were observed in patients with AFib.

      This brings to the concept of AFib treatment while interfering on tissue remodeling by the
      way of renin-angiotensin system. Drugs such as the angiotensin converting enzyme inhibition
      [ACEI] may reduce AFib in patients with heart failure. No randomized study so far has
      compared the ACEI drugs against placebo among high-risk patients of AFib in post AFL RFA
      area. On the basis of experimental and clinical study, the investigators seek to evaluate the
      ACEI use in the prevention of AFib in an AFL post RFA ablation.
    
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