Ranolazine plus AAD helps maintain sinus rhythm after DCCV in persistent AF

Treatment with ranolazine in combination with class III antiarrhythmic drugs (AADs) is associated with improved maintenance of sinus rhythm (SR) 1 year after DC cardioversion (DCCV) relative to class III AAD alone, according to a study presented at EHRA 2024.

“Ranolazine also shows comparable efficacy to traditional class III agents and could therefore be considered as an alternative for patients in whom a class III AAD is not desirable,” said lead researcher Dr Sagarika Raman from the Newcastle Upon Tyne Hospitals NHS Foundation Trust, UK.

Raman and colleagues performed a retrospective review of DCCV lists from June 2020 to February 2022. They included 350 patients who underwent DCCV on a class III AAD (ie, amiodarone or dronedarone), ranolazine, or a combination of both and with 1 year of follow-up. Those who underwent atrial fibrillation (AF) ablation during follow-up were excluded.

Finally, the researchers recorded acute DCCV success and maintenance of SR at 1-year follow-up.

Of the participants, 102 (29.1 percent) received AAD, and 78 remained after exclusions. Among the included patients, 30 were on amiodarone, 23 on dronedarone, 11 on ranolazine, and 14 on ranolazine plus class III AAD. [Raman S, et al, EHRA 2024]

Majority (48/53, 90.6 percent) of the patients taking any class III AAD (amiodarone: 27/30, 90.0 percent; dronedarone: 21/23, 91.3 percent) achieved SR acutely following DCCV, as did 10 of 11 (90.9 percent) treated with ranolazine and all (14/14, 100 percent) of those who received ranolazine plus class III AAD.

Sustained SR

At 1-year follow-up, the number of patients who remained in SR was 16/53 (30.2 percent; amiodarone: 12/30, 40.0 percent; dronedarone: 4/23, 17.4 percent) with any class III AAD, 3/11 (27.2 percent) with ranolazine, and 8/14 (53.3 percent) with ranolazine plus class III AAD.

“Despite including five patients (35.3 percent) who had previously failed an AAD monotherapy, the group taking a combination of ranolazine and a class III AAD were numerically more likely to remain in SR at 1-year follow-up than those on amiodarone or ranolazine, though neither reached significance,” according to Raman and colleagues.

On the other hand, combined treatment with ranolazine plus class III AAD demonstrated greater efficacy than treatment with dronedarone alone (p=0.03). In addition, a trend towards improved efficacy was noted with the combination therapy compared with any class III AAD (53.3 percent vs 30.2 percent; p=0.11). No significant differences were observed among the three monotherapy treatments.

“Larger randomized multicentre trials are warranted to evaluate the efficacy and safety of these treatment strategies,” Raman said.

DCCV is used to treat irregular heart rhythms in patients with persistent AF, while the use of AADs increases the rates of acute conversion and longer-term maintenance of SR post-DCCV. Amiodarone is considered the most effective AAD but is associated with several side-effects.

“Ranolazine, currently licensed for angina, has been shown to have AF-suppressive effects and works synergistically with class III AADs,” Raman said.