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Effects of Dronedarone on Cardiovascular
Events: a New Antiarrhythmic Drug
Grace ThackerXavier University of LouisianaLSUHC – Internal Medicine
April 7, 2009
Effects of Dronedarone on Cardiovascular
Events in Atrial Fibrillation
New England Journal of Medicine February 2009, 360: 668-678Hohnloser, S., Crijns, H., van Eickels, M., Gaudin, C., Page, R., Torp-Pederson, C., & Connolly, S.
Why ATHENA?
Novel drug Recent FDA approval of Multaq First study of its kind
– Antiarrhythmic– Hospitalization
What is ATHENA?
Randomized double blind placebo controlled trial
Multi-center – 551 centers– 37 countries
Phase III research
Abstract & Title
Abstract:– Clear and concise– No new information– Lets the reader know if article is worth
reading Title
– Does not! Not very representative!
Authors & Funding
Authors are affiliated with various universities and medical centers
All received monies from Sanofi-Aventis Investigators from ATHENA contributed
to study design and protocol Study was funded by Sanofi-Aventis
Background
Purpose: more data for new drug Background: current atrial fibrillation
therapy is limited by toxicities – Dronedarone formulated to avoid some
toxicities Goal: determine if dronedarone reduced
hospitalizations due to cardiovascular causes
Dronedarone
O
CH3
OI
I
O
N
CH3
CH3
Dronedarone is a modification of amiodarone. Note that dronedarone does not contain iodine, and has the addition of a methane-sulfonyl group that reduces lipophilicity to decrease accumulation in tissue.
dronedarone
amiodarone
Methods
Randomized double blind placebo controlled
Enrollment: June 2005 – December 30 2006
Follow up: until common end day of December 30 2007
Enrollment
Inclusion criteria:– Atrial fibrillation or flutter demonstrated by
EKG within last 6 months– Plus EKG showing normal sinus rhythm in
same time period– Plus one or more additional requirements
Enrollment
Inclusion criteria: One or more of the following:
– Age of at least 70– HTN – DM – Previous stroke, systemic embolism, or TIA – LA diameter >/= 50 mm, or LEF </= 40%.
Enrollment
Exclusion criteria: – Heart failure. NYHA class IV, or recent
decompensation– bradycardia or PR interval >0.28 seconds– Permanent A fib, acute myocarditis, sinus
node disease– Need for class I or class III antiarrhythmic
Enrollment
Changes in May 2006:– Inclusion criteria altered to include
• Patients age 75 or older with no additional factors present
• Patients age 70 – 74 had to demonstrate one or more additional factors
Outcomes
Primary: composite outcome of hospitalization due to cardiovascular events, and death from any cause
Secondary: death from any cause, death from cardiovascular events, hospitalization due to cardiovascular events
Study power
Required 970 primary outcome events to be powered at 80% to detect a 15% difference
Minimum follow up 1 year; maximum follow up 2.5 years
Assumed enrollment of 2150 patients per group
Randomization
Dronedarone: 2301; 10 not treated; 696 discontinued drug prematurely
Placebo: 2325; 2 lost to follow up; 14 not treated; 716 discontinued drug prematurely
Randomization stratified per center and by presence of A fib or A flutter at enrollment
Randomization
Baseline characteristics: no difference between groups– Most common CV disorder: HTN– A fib or A flutter present in 25%– Structural heart disease in 59.6%– Heart failure: Class II in 17%; Class III in
4.4%
Results
Primary Outcome: – Dronedarone: 31.9%– Placebo: 39.4%– Hazard ratio 0.76 (95% CI 0.69-0.86, P <
0.001)
Results
Secondary Outcomes:– Death from any cause: no difference– Death from cardiovascular causes:
dronedarone 2.7%, placebo 3.9%, P = 0.03– Death from arrhythmias: dronedarone
1.1%, placebo 2.1%, P = 0.01– Hospitalization for CV events: dronedarone
36.9%, placebo 29.3%, P< 0.001
Drug discontinuation
Over 30% in both groups Dronedarone: adverse events.
– Most significant: rash, nausea, diarrhea, bradycardia, QT prolongation, increased serum creatinine
Placebo: “other”– Required drugs not allowed by the study
Discussion
Unlike ANDROMEDA, dronedarone demonstrated a decrease in death– Excluded severe heart failure– Heart failure subgroup showed same
benefit – Amiodarone still drug of choice in severe
heart failure Decrease in hospitalizations
– Cannot be compared to other drugs
Discussion
Fewer side effects than amiodarone– Short term study – Need longer follow up to assess long term
toxicities– Need comparison trial with amiodarone
• Study completed March 2009• Compares amiodarone and dronedarone in
preventing recurrent atrial fibrillation
Limitations
High rates of discontinuation Inclusion criteria
– Only age 70 and up– Change in inclusion criteria
Not comparable to other antiarrhythmic trials
Application
Consider dronedarone to avoid toxicities such as thyroid dysfunction or pulmonary toxicities
Continue to rely on amiodarone or dofetilide for patients with NYHA HF III or IV
Keep cost and formulary issues in mind Refer to handout for additional information on
dronedarone