Addressing the management of atrial fibrillation – a systematic review of the role of dronedarone

Gian Marco Podda,¹ Giovanni Casazza,² Francesco Casella,³ Franca Dipaola,⁴ Emanuela Scannella,³ Ludovica Tagliabue<sup>5

1</sup>Medicina III, Department of Medicine, Surgery and Dentistry, San Paolo Hospital, University of Milan, Milan, Italy; ²Department of Clinical Science, "L. Sacco", University of Milan, Milan, Italy; ³Department of Internal Medicine, L. Sacco Hospital, Milan, Italy; ⁴Internal Medicine, Istituti Clinici di Perfezionamento Sesto San Giovanni, Italy; ⁵School of Hygiene and Preventative Medicine, University of Milan, Milan, Italy

Background: Atrial fibrillation (AF) is the most common sustained arrhythmia. It occurs in 1%–2% of the general population and its prevalence increases with age. Dronedarone, a noniodinated benzofuran similar to amiodarone, was developed as an antiarrhythmic agent for patients with atrial fibrillation. The aim of our systematic review was to critically evaluate randomized controlled trials that compared treatment with dronedarone versus placebo or amiodarone in patients with atrial fibrillation.
Methods: Electronic databases (MEDLINE, Embase, and Central) were searched up to November 2011 with no language restrictions. We included randomized controlled trials in which dronedarone was compared to placebo or other drugs in patients with AF. Internal and external validity was assessed.
Results: We identified seven papers corresponding to eight randomized controlled trials. The DAFNE, EURIDIS/ADONIS, and ATHENA trials demonstrated a reduction of AF recurrence with dronedarone as compared to placebo in patients with nonpermanent AF. The DIONYSOS study showed that dronedarone is less effective for the prevention of recurrent AF but improved tolerability as compared to amiodarone. Considering patients with permanent AF, the ERATO trial showed that dronedarone had rate-control effects while the PALLAS study was stopped early since stroke, myocardial infarction, systemic embolism, or death from cardiovascular causes were significantly more frequent in subjects treated with dronedarone as compared to placebo. The ANDROMEDA trial included patients with recent hospitalization for heart failure and was terminated early because of excess of deaths in the dronedarone group.
Conclusion: Like most antiarrhythmic drugs, dronedarone reduces the recurrence of AF in patients with paroxysmal or persistent AF as compared to placebo. However, relapse rates in the first year of therapy are high. Moreover, dronedarone showed to be less effective than amiodarone. Finally, dronedarone should be avoided in patients with permanent AF and a high risk for cardiovascular events or severe congestive heart failure.
Keywords: amiodarone, arrhythmia, cardiovascular events