A 75-year-old diabetic woman with a history of previous MI and an LVEF of 35% has been on amiodarone for paroxysmal AF for several years. On examination she is breathless at rest and has signs of congestive cardiac failure. She has heard about dronedarone and is wondering whether she can have it instead of amiodarone.
What do you advise her about dronedarone?
This woman appears to be in NYHA class IV heart failure and thus dronedarone is contraindicated according to NICE guidelines. Dronedarone is a structural analogue of amiodarone, but does not contain iodine and thus has a lower risk of skin, lung, and eye side effects. The ATHENA study showed a 24% relative risk reduction of the combined endpoint of cardiovascular hospitalization and death compared with placebo (mainly driven by a reduction in cardiovascular hospitalizations, especially for AF). Dronedarone was also found to reduce the ventricular rate response during AF by 10–15 bpm. Dronedarone is contraindicated in NYHA class III–IV heart failure but is recommended by NICE as an option in patients whose AF is not controlled by first-line therapy and who have at least one of the following risk factors: hypertension (requiring at least two different drugs), diabetes, previous TIA/stroke, LA ≥ 50 mm, LVEF ≤ 40%, and ≥70 years old. There is no evidence that dronedarone is more effective than amiodarone at maintaining sinus rhythm.