Letter by Barrios et al Regarding Article, “Influence of Systolic and Diastolic Blood Pressure on the Risk of Incident Atrial Fibrillation in Women”
To the Editor:
Conen et al1 have recently analyzed the impact of systolic and diastolic blood pressure (BP) on the risk of new-onset atrial fibrillation (AF) among initially healthy, middle-aged women. For this purpose, the authors prospectively followed up a total of 34 221 women participating in the Women’s Health Study. In this large cohort of women, BP was strongly associated with incident AF. Notably, systolic BP was a better predictor than diastolic BP. Interestingly, systolic BP levels within the nonhypertensive range were independently associated with incident AF even after BP changes over time.
Inasmuch as AF increases cardiovascular morbidity and mortality, the results of this study are of great clinical relevance. As is known, cardiovascular disease is a continuum, starting with risk factors, extending to organ damage, and ending with clinical outcomes. If even small elevations of BP values raise the risk of incident AF in healthy women, what could happen in higher-risk individuals? A markedly increased risk of AF in hypertensive patients with coronary heart disease has been reported, particularly in women,2 which could be closely related to the lower BP control rates observed in women.2,3 Current guidelines suggest that for preventing cardiovascular disease a global approach that considers concomitantly all associated risk factors and comorbidities is mandatory.4 Available data have shown that patients with AF have more cardiovascular risk factors and comorbidities.2 Taking into account that risk factors control is worse in individuals with AF, the next question to be answered is whether AF is a marker of risk or is directly a cardiovascular risk factor by itself. Although AF is not actually considered in the current risk stratification, as the authors suggest, future hypertension guidelines should assign a more important role to AF for cardiovascular risk stratification in patients with hypertension.
By contrast, it has been suggested that a high resting heart rate increases cardiovascular outcomes, especially in hypertension and in ischemic heart disease. However, in contrast with individuals at sinus rhythm, it has been reported that in patients with AF, a higher heart rate is less related to a worse clinical profile.5 Although only data about BP values are reported by Conen et al, it would be valuable to analyze whether the baseline heart rate may have any influence on the risk of incident AF.
Conen D, Tedrow UB, Koplan BA, Glynn RJ, Buring JE, Albert CM. Influence of systolic and diastolic blood pressure on the risk of incident atrial fibrillation in women. Circulation. 2009; 119: 2146–2152.
Keyhani S, Scobie JV, Hebert PL, McLaughlin MA. Gender disparities in blood pressure control and cardiovascular care in a national sample of ambulatory care visits. Hypertension. 2008; 51: 1149–1155.
Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, Grassi G, Heagerty AM, Kjeldsen SE, Laurent S, Narkiewicz K, Ruilope L, Rynkiewicz A, Schmieder RE, Boudier HA, Zanchetti A, Vahanian A, Camm J, De Caterina R, Dean V, Dickstein K, Filippatos G, Funck-Brentano C, Hellemans I, Kristensen SD, McGregor K, Sechtem U, Silber S, Tendera M, Widimsky P, Zamorano JL, Erdine S, Kiowski W, Agabiti-Rosei E, Ambrosioni E, Lindholm LH, Viigimaa M, Adamopoulos S, Agabiti-Rosei E, Ambrosioni E, Bertomeu V, Clement D, Erdine S, Farsang C, Gaita D, Lip G, Mallion JM, Manolis AJ, Nilsson PM, O'Brien E, Ponikowski P, Redon J, Ruschitzka F, Tamargo J, van Zwieten P, Waeber B, Williams B. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2007; 25: 1105–1187.
Barrios V, Escobar C, Echarri R. Atrial fibrillation and coronary heart disease: fatal attraction. J Atr Fibrillation. 2009; 1: 262–269.