title: Effect of Aggressive Blood Pressure Control on the Recurrence of Atrial Fibrillation After Catheter Ablation: A Randomized, Open-Label Clinical Trial (SMAC-AF [Substrate Modification With Aggressive Blood Pressure Control]).
abstract: BACKGROUND
  Radiofrequency catheter ablation for atrial fibrillation has become an important therapy for AF; however, recurrence rates remain high. We proposed to determine whether aggressive blood pressure (BP) lowering prevents recurrent atrial fibrillation (AF) after catheter ablation in patients with AF and a high symptom burden.
  
  
  METHODS
  We randomly assigned 184 patients with AF and a BP >130/80 mm Hg to aggressive BP (target <120/80 mm Hg) or standard BP (target <140/90 mm Hg) treatment before their scheduled AF catheter ablation. The primary outcome was symptomatic recurrence of AF/atrial tachycardia/atrial flutter lasting >30 seconds, determined 3 months beyond catheter ablation by a blinded end-point evaluation.
  
  
  RESULTS
  The median follow-up was 14 months. At 6 months, the mean systolic BP was 123.2±13.2 mm Hg in the aggressive BP treatment group versus 135.4±15.7 mm Hg (P<0.001) in the standard treatment group. The primary outcome occurred in 106 patients, 54 (61.4%) in the aggressive BP treatment group compared with 52 (61.2%) in the standard treatment group (hazard ratio=0.94; 95% confidence interval, 0.65-1.38;P=0.763). In the prespecified subgroup analysis of the influence of age, patients ≥61 years of age had a lower primary outcome event rate with aggressive BP (hazard ratio=0.58; 95% confidence interval, 0.34-0.97;P=0.013). There was a higher rate of hypotension requiring medication adjustment in the aggressive BP group (26% versus 0%).
  
  
  CONCLUSIONS
  In this study, this duration of aggressive BP treatment did not reduce atrial arrhythmia recurrence after catheter ablation for AF but resulted in more hypotension.
  
  
  BACKGROUND
  URL: http://www.clinicaltrials.gov. Unique identifier: NCT00438113.
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.). ratika.parkash@nshealth.ca.
authors.forename: Ratika
authors.initials: R
authors.lastname: Parkash
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: George A
authors.initials: GA
authors.lastname: Wells
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: John L
authors.initials: JL
authors.lastname: Sapp
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Healey
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: Jean-Claude
authors.initials: JC
authors.lastname: Tardif
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: Isabelle
authors.initials: I
authors.lastname: Greiss
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: Lena
authors.initials: L
authors.lastname: Rivard
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: Jean-Francois
authors.initials: JF
authors.lastname: Roux
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: Lorne
authors.initials: L
authors.lastname: Gula
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: Isabelle
authors.initials: I
authors.lastname: Nault
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: Paul
authors.initials: P
authors.lastname: Novak
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: David
authors.initials: D
authors.lastname: Birnie
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: Andrew
authors.initials: A
authors.lastname: Ha
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Wilton
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: Iqwal
authors.initials: I
authors.lastname: Mangat
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: Christopher
authors.initials: C
authors.lastname: Gray
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: Martin
authors.initials: M
authors.lastname: Gardner
authors.affiliation: From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).
authors.forename: Anthony S L
authors.initials: ASL
authors.lastname: Tang
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy*; D001794:Blood Pressure / Q000502:physiology*; D001795:Blood Pressure Determination / Q000379:methods / Q000639:trends*; D017115:Catheter Ablation / Q000379:methods / Q000639:trends*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D016896:Treatment Outcome
keywords: atrial fibrillation; catheter ablation; hypertension