From the Guidelines
Daridorexant should be used with caution in patients with heart failure and atrial fibrillation, and only after careful consideration by a cardiologist. This medication is a dual orexin receptor antagonist approved for insomnia treatment, typically prescribed at 25-50 mg once daily before bedtime. While daridorexant doesn't have specific contraindications for heart failure or atrial fibrillation, there are important concerns. The medication can potentially cause QT interval prolongation, which may worsen arrhythmias in patients with existing cardiac conditions. Additionally, daridorexant may interact with medications commonly prescribed for heart failure and atrial fibrillation, such as antiarrhythmics, anticoagulants, and certain beta-blockers. If prescribed, patients should be monitored for worsening cardiac symptoms, including increased shortness of breath, palpitations, or edema. Starting at the lowest effective dose (25 mg) is advisable to minimize potential cardiovascular effects. Alternative insomnia treatments like cognitive behavioral therapy for insomnia (CBT-I) might be safer first-line options for these patients. The underlying mechanism of concern relates to how orexin receptor antagonists may influence autonomic nervous system function, which already tends to be dysregulated in heart failure and atrial fibrillation patients 1.
Some key considerations for managing heart failure and atrial fibrillation include:
- Pharmacological rate control during atrial fibrillation, with a beta-blocker or digoxin recommended to control the heart rate at rest in patients with HF and LV dysfunction 1
- A combination of digoxin and a beta-blocker may be considered to control the heart rate at rest and during exercise 1
- Intravenous administration of digoxin or amiodarone is recommended to control the heart rate in patients with AF and HF, who do not have an accessory pathway 1
- Atrioventricular node ablation and pacing should be considered to control the heart rate when other measures are unsuccessful or contraindicated 1
It is essential to weigh the potential benefits of daridorexant against the potential risks and consider alternative treatments for insomnia in patients with heart failure and atrial fibrillation. Regular monitoring and close collaboration with a cardiologist are crucial to ensure the safe use of daridorexant in these patients. The most recent and highest quality study 1 provides guidance on the management of heart failure and atrial fibrillation, which should be taken into consideration when making treatment decisions for these patients.
From the Research
Atrial Fibrillation and Heart Failure
- Atrial fibrillation is a common arrhythmia in patients with heart failure, and its presence can deteriorate cardiac function and increase the risk of thromboembolic events 2, 3.
- The management of patients with atrial fibrillation in association with heart failure should consist of ventricular rate control, prevention of thromboembolic events, and conversion to normal sinus rhythm 3.
- Guideline-directed pharmacological and device therapy for heart failure is essential, and the management options for atrial fibrillation and heart failure include pharmacological rhythm control, pharmacological rate control, and interventional approaches 4.
Treatment Options
- Traditionally, digoxin has been widely used in patients with heart failure and atrial fibrillation; however, it does very little to restore sinus rhythm and requires the addition of another rate-limiting agent to control ventricular rate 3.
- Amiodarone has been evaluated in numerous clinical trials and appears to be safe and effective when used in low dosage 3.
- Catheter ablation for atrial fibrillation in patients with heart failure and reduced ejection fraction has shown superiority in improving survival, quality of life, and ventricular function and reducing heart failure hospitalizations compared with antiarrhythmic drugs and rate control therapies 5, 6.
Daridorexant (Quviviq) Use
- There is no direct evidence in the provided studies regarding the use of daridorexant (Quviviq) in patients with heart failure and atrial fibrillation.
- The studies primarily focus on the management of atrial fibrillation in patients with heart failure, including pharmacological and interventional approaches, but do not mention daridorexant (Quviviq) as a treatment option 2, 3, 5, 4, 6.