Lower Risk of Conduction Disorders With Lisinopril Treatment

By Will Boggs MD

NEW YORK - Treatment with lisinopril is associated with a lower risk of developing conduction disorders, according to a secondary analysis of the ALLHAT study.

"We need to move away from the concept that 'preventive cardiology' refers only to the prevention of coronary disease and to start thinking about how we might prevent other common cardiac disorders, such as arrhythmias," said Dr. Gregory M. Marcus from the University of California, San Francisco.

"We believe this paper provides an important initial proof of concept, that conduction disease may indeed be preventable," he told Reuters Health by email.

Dr. Marcus and colleagues used data from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) to examine whether antihypertensives and/or therapy to lower lipid levels might affect the development of incident conduction disorders. They also studied the effect of other clinical characteristics in their analysis of more than 21,000 trial participants.

Dr. Marcus said, "This research was specifically motivated by several of my patients in whom I have implanted pacemakers for complete heart block (the most severe and final form of conduction disease) that have asked me, 'why did this happen to me?' and 'was there anything I could have done to avoid this?'"

Overall, the incidence of any conduction abnormality was 13.0 per 1,000 person-years. Independent predictors of new conduction abnormalities included older age, male sex, increased body mass index, tobacco use, diabetes, coronary heart disease, and left ventricular hypertrophy.

Black patients, on the other hand, had a 41% lower risk of conduction disorders compared with non-Hispanic white patients.

Participants randomized to lisinopril treatment were 19% less likely than those randomized to chlorthalidone therapy to develop conduction disorders, the researchers report in JAMA Internal Medicine, online June 27.

Randomization to amlodipine or pravastatin, however, was not associated with significant differences in conduction outcome events.

"The most interesting and promising results included this new observation that a commonly prescribed and well-tolerated drug might actually alter the natural history of this disease by reducing the likelihood that one might develop conduction disease," Dr. Marcus said. "We also identified several predictors of new conduction disease that are theoretically modifiable, such as smoking and diabetes."

"These data provide more evidence in favor of a healthy lifestyle to potentially avoid conduction disease that may lead to heart failure and/or require a pacemaker," he said. "Specifically, we provide yet another reason to counsel smoking cessation and, to reduce the risk of diabetes and coronary disease, a healthy diet and regular exercise."

"The primary finding, that lisinopril reduces the risk of conduction disease, likely requires replication and perhaps a prospective randomized trial before it can be recommended in clinical practice for the purpose of preventing conduction disease," Dr. Marcus concluded. "However, our hope is that this research may be sufficiently convincing to motivate such investigation."

Dr. David J. Maron from Stanford University in California, who co-authored an accompanying commentary, told Reuters Health by email, "Unless there is a compelling reason to use another drug or not to use an ACE inhibitor, lisinopril should be strongly considered as the agent of choice for people 55 and older with hypertension and at least one additional atherosclerosis risk factor."

"It may be possible to prevent conduction system disease with drugs that we prescribe commonly," he said. "This is fertile ground for additional research, including discovery if such therapies prevent the need for pacemakers."

Dr. Maron added, "Learning the mechanism of benefit from lisinopril may lead to the discovery of other agents that have even greater preventive effects."

SOURCE: https://bit.ly/28ZvMsz and https://bit.ly/29350xu

JAMA Intern Med 2016.

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