title: Impact of controlling atrial fibrillation on outcomes relevant to the patient: focus on dronedarone.
abstract: Atrial fibrillation (AF) is a substantial cause of mortality and morbidity in the Western world. It is a massive burden on health care systems, and its prevalence is expected to double over the next 20 years. Trials evaluating antiarrhythmic drugs or catheter ablation have focused on recurrence of arrhythmia, perhaps neglecting outcomes relevant to patients, such as symptoms, need for antiarrhythmic drugs, need for hospitalization, and rates of stroke and death. An association has been demonstrated between sinus rhythm and survival in several studies, and there is evidence emerging that successful catheter ablation may reduce rates of stroke and death. Similarly, dronedarone has been shown to reduce hospitalizations and death in patients with paroxysmal AF or persistent AF of recent onset, although it may cause adverse events in permanent AF. New antiarrhythmic drugs are a welcome addition to the armamentarium, since there are limitations to current antiarrhythmic drugs. In particular, sotalol, flecainide, and propafenone cannot be used safely in those with structural heart disease, and amiodarone has important adverse reactions that limit long-term use. Indeed, the use of conventional antiarrhythmic drugs may negate any survival benefit derived from maintaining sinus rhythm. Although dronedarone appears promising with respect to hard endpoints such as stroke and death in certain patients, it may not be safe for those with heart failure or those with permanent AF. Furthermore, the trials suggesting that dronedarone may impact on these endpoints were compared with placebo rather than with an active comparator group. Further "head-to-head" comparisons between dronedarone and other antiarrhythmic drugs are needed to determine whether this property is unique to dronedarone alone.
authors: Department of Cardiology Research, St Bartholomew's Hospital, London, United Kingdom.
authors: C Anwar A
authors: CA
authors: Chahal
authors: Omer
authors: O
authors: Ali
authors: Ross J
authors: RJ
authors: Hunter
authors: Richard J
authors: RJ
authors: Schilling
keywords: ablation; antiarrhythmics; atrial fibrillation; dronedarone; rhythm; stroke
references: Am Heart J. 2008 Sep;156(3):527.e1-9
references: 18760136
references: JAMA. 2010 Jan 27;303(4):333-40
references: 20103757
references: Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005049
references: 17943835
references: J Am Coll Cardiol. 2004 Jan 21;43(2):241-7
references: 14736444
references: J Am Coll Cardiol. 2003 Jul 16;42(2):185-97
references: 12875749
references: J Am Coll Cardiol. 2011 Jan 18;57(3):313-21
references: 21232669
references: J Am Coll Cardiol. 2008 Feb 26;51(8):843-9
references: 18294570
references: JAMA. 2005 Jun 1;293(21):2634-40
references: 15928285
references: Heart. 2010 Sep;96(17):1372-8
references: 20483892
references: Eur J Pharmacol. 1995 Jun 6;279(1):25-32
references: 7556379
references: JAMA. 2001 May 9;285(18):2370-5
references: 11343485
references: J Am Coll Cardiol. 2006 Dec 5;48(11):2340-7
references: 17161267
references: J Am Coll Cardiol. 2010 Feb 23;55(8):735-43
references: 20170810
references: N Engl J Med. 2002 Dec 5;347(23):1825-33
references: 12466506
references: J Am Coll Cardiol. 2009 Sep 15;54(12):1089-95
references: 19744618
references: Circ Arrhythm Electrophysiol. 2011 Oct;4(5):637-43
references: 21841207
references: J Am Coll Cardiol. 2011 Jan 11;57(2):223-42
references: 21177058
references: J Cardiovasc Electrophysiol. 2010 Jun 1;21(6):597-605
references: 20384650
references: J Cardiovasc Electrophysiol. 2011 Aug;22(8):839-45
references: 21410581
references: N Engl J Med. 2008 Jun 19;358(25):2678-87
references: 18565860
references: N Engl J Med. 2006 Mar 2;354(9):934-41
references: 16510747
references: J Cardiovasc Pharmacol. 2003 Feb;41(2):191-202
references: 12548079
references: Circulation. 2008 Dec 9;118(24):2498-505
references: 19029470
references: J Cardiovasc Electrophysiol. 2007 Jan;18(1):9-14
references: 17081210
references: Br J Clin Pharmacol. 2007 Dec;64(6):785-91
references: 17662087
references: Circulation. 2004 Mar 30;109(12):1509-13
references: 15007003
references: J Cardiovasc Electrophysiol. 2006 Sep;17 Suppl 2:S17-20
references: 16939434
references: N Engl J Med. 2007 Sep 6;357(10):987-99
references: 17804843
references: Europace. 2007 Jun;9(6):335-79
references: 17599941
references: Eur Heart J. 2006 Jan;27(2):216-21
references: 16214831
references: Eur Heart J. 2003 Aug;24(16):1481-7
references: 12919771
references: Circ Cardiovasc Qual Outcomes. 2011 May;4(3):313-20
references: 21540439
references: N Engl J Med. 2009 Feb 12;360(7):668-78
references: 19213680
references: N Engl J Med. 2011 Dec 15;365(24):2268-76
references: 22082198
references: Europace. 2009 Apr;11(4):402-4
references: 19223364
references: N Engl J Med. 2004 Dec 2;351(23):2373-83
references: 15575053
references: Indian Pacing Electrophysiol J. 2009 Sep 01;9(5):260-7
references: 19763194
references: Heart Rhythm. 2008 Nov;5(11):1501-7
references: 18842464
references: N Engl J Med. 2008 Oct 23;359(17):1778-85
references: 18946063
references: Pharmacotherapy. 2010 Sep;30(9):904-15
references: 20795846
references: Heart. 2012 Jan;98(1):48-53
references: 21930724
references: Stroke. 1991 Aug;22(8):983-8
references: 1866765
references: Heart. 2006 Feb;92(2):155-61
references: 16159980
references: Pacing Clin Electrophysiol. 2006 Sep;29(9):962-70
references: 16981920
references: Am J Cardiol. 2009 Dec 1;104(11):1534-9
references: 19932788
references: Eur Heart J. 2012 Nov;33(21):2719-47
references: 22922413
references: Cardiovasc Drug Rev. 2005 Fall;23(3):217-30
references: 16252015
references: J Cardiovasc Electrophysiol. 2012 May;23(5):462-72
references: 22171925