How long should I stay on Multaq (dronedarone) after converting to sinus rhythm?

Duration of Multaq (Dronedarone) After Cardioversion to Sinus Rhythm

Multaq should be continued indefinitely after cardioversion to sinus rhythm, with cardiac rhythm monitoring at least every 3 months—if atrial fibrillation recurs, either cardiovert again or discontinue Multaq, as it offers no benefit in permanent AF and significantly increases mortality and stroke risk. 1

Critical Monitoring Requirements

Rhythm monitoring is mandatory and non-negotiable:

• Check cardiac rhythm at minimum every 3 months while on Multaq 1
• If AF is detected during monitoring, you have two options: cardiovert the patient back to sinus rhythm (if clinically appropriate) or discontinue Multaq 1
• Multaq is contraindicated in permanent AF—it doubles the risk of cardiovascular death and stroke in this population 1

Why Indefinite Continuation is Necessary

Multaq's indication is rhythm maintenance, not just acute conversion:

• Dronedarone is indicated specifically to reduce the risk of hospitalization for AF in patients who remain in sinus rhythm with a history of paroxysmal or persistent AF 1
• Clinical trials (EURIDIS, ADONIS) demonstrated dronedarone maintains sinus rhythm better than placebo, with median time to recurrence extending from 41-59 days (placebo) to 96-158 days (dronedarone) 2
• The ATHENA trial showed continued benefit with reduced cardiovascular hospitalizations and stroke (1.2% vs 1.8% annually) in patients maintained on dronedarone 3

Anticoagulation Considerations Separate from Dronedarone Duration

Do not confuse anticoagulation duration with antiarrhythmic duration:

• After cardioversion, therapeutic anticoagulation is required for at least 4 weeks regardless of baseline stroke risk 4
• However, decisions about anticoagulation beyond 4 weeks should be based on CHA₂DS₂-VASc score and stroke risk factors, not on whether the patient remains in sinus rhythm 4
• Multaq should only be initiated in patients already receiving appropriate antithrombotic therapy 1

When to Discontinue Multaq

Stop dronedarone immediately if:

• Patient develops permanent AF (rhythm cannot be restored) 1
• New or worsening heart failure requiring hospitalization occurs 1
• Signs of hepatic injury appear (anorexia, nausea, jaundice, dark urine, right upper quadrant pain) 1
• QTc Bazett interval reaches ≥500 ms 1
• Patient develops symptomatic bradycardia or heart block 1

Common Pitfall to Avoid

The 4-week anticoagulation rule does NOT apply to dronedarone duration:

• Many clinicians mistakenly stop antiarrhythmic drugs at 4 weeks post-cardioversion, confusing this with the minimum anticoagulation period 4
• Dronedarone's purpose is ongoing rhythm maintenance—stopping it at 4 weeks defeats its therapeutic intent 1, 2
• AF recurrence rates are 71-84% at 1 year without antiarrhythmic maintenance therapy 5

Practical Algorithm

1. Cardiovert to sinus rhythm (electrical or pharmacological)
2. Start/continue appropriate anticoagulation for minimum 4 weeks 4
3. Continue Multaq 400 mg twice daily with meals indefinitely 1
4. Monitor rhythm every 3 months minimum 1
5. If AF recurs: Attempt cardioversion OR discontinue Multaq 1
6. Continue anticoagulation long-term based on CHA₂DS₂-VASc score, not rhythm status 4