Can discontinuing (d/c) Valsartan (valsartan) cause patients to experience atrial fibrillation (afib) flare-ups?

Discontinuing Valsartan Can Trigger Atrial Fibrillation Flares

Yes, discontinuing valsartan can cause patients to experience atrial fibrillation flares, particularly in patients with heart failure or cardiovascular disease. 1 The abrupt withdrawal of renin-angiotensin-aldosterone system (RAAS) inhibitors like valsartan can disrupt the cardiac remodeling benefits these medications provide.

Mechanism and Evidence

Valsartan and other angiotensin receptor blockers (ARBs) have been shown to:

• Reduce the incidence of atrial fibrillation in patients with heart failure by approximately 37% 2
• Prevent adverse cardiac remodeling that contributes to arrhythmia development
• Provide electrical stabilization of cardiomyocytes 3

When valsartan is discontinued:

1. The protective effects against atrial remodeling are lost
2. RAAS activation resumes, potentially triggering arrhythmias
3. Patients with heart failure may experience clinical deterioration 1

Risk Factors for AF Flares After Valsartan Discontinuation

Patients at highest risk for AF flares after valsartan discontinuation include:

• Those with pre-existing heart failure with reduced ejection fraction (HFrEF)
• Patients with a history of previous AF episodes
• Individuals with left atrial enlargement
• Patients with elevated BNP levels (a strong independent predictor for AF occurrence) 2
• Elderly patients (>70 years) 2

Management Recommendations

If discontinuation of valsartan is necessary:

1. Consider transitioning to an alternative ARB or ACE inhibitor rather than complete discontinuation 1

   • This is especially important for patients with heart failure or previous AF

2. Implement enhanced electrocardiographic monitoring for early detection of AF recurrence 1

   • Instruct patients to monitor their pulse daily
   • Consider wearable devices for high-risk patients

3. Educate patients about symptoms of AF recurrence (palpitations, shortness of breath, fatigue)

   • Advise them to seek medical attention if symptoms develop

4. Maintain other cardioprotective medications (beta-blockers, mineralocorticoid receptor antagonists) if appropriate

Special Considerations

Heart Failure Patients

In patients with HFrEF, discontinuing valsartan can lead to:

• Worsening of NYHA functional class
• Deterioration of left ventricular ejection fraction
• Increased risk of heart failure hospitalization 4

If valsartan must be discontinued in these patients, replacement with another RAAS inhibitor is strongly recommended.

Patients with Chronic Lymphocytic Leukemia on BTK Inhibitors

Patients receiving ibrutinib or other BTK inhibitors have a high incidence of AF (3-16%). For these patients:

• Valsartan may help manage hypertension and reduce AF risk
• Discontinuation should be carefully considered and monitored 1

Common Pitfalls to Avoid

1. Abrupt discontinuation without replacement therapy - This can lead to rebound RAAS activation
2. Failure to monitor for AF recurrence after discontinuation
3. Overlooking the need for alternative RAAS inhibition in high-risk patients
4. Not recognizing early signs of AF recurrence - Subtle symptoms may precede obvious arrhythmias

While not all patients will experience AF flares after valsartan discontinuation (as seen in the GISSI-AF study where valsartan did not reduce AF recurrence in all patients 5, 6), those with underlying heart failure or structural heart disease are at particular risk and require careful monitoring if valsartan therapy must be discontinued.