From the Guidelines
Amiodarone is safe in patients with heart failure and does not precipitate heart failure, according to the most recent and highest quality study. The 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS state that amiodarone is an effective multichannel blocker, reduces ventricular rate, and is safe in patients with heart failure 1. This suggests that amiodarone can be used in patients with heart failure without increasing the risk of worsening heart failure. However, it's essential to monitor patients for signs of heart failure, such as increasing shortness of breath, edema, weight gain, or decreased exercise tolerance, as amiodarone can cause extracardiac side-effects, especially on long-term therapy 1.
Some key points to consider when using amiodarone in patients with heart failure include:
- Amiodarone has a negative inotropic effect, which can decrease the heart's contractility and pumping efficiency, but this effect is not significant enough to precipitate heart failure in most patients 1.
- The risk of heart failure is not increased with amiodarone use, and it can be used as a second-line treatment in patients who are suitable for other antiarrhythmic drugs 1.
- Patients taking amiodarone should be monitored for signs of heart failure, and dose reduction or discontinuation may be necessary if heart failure symptoms develop or worsen 1.
- Amiodarone is not recommended for general use in patients with heart failure due to its high incidence of drug toxicity, but it can be used in cases of symptomatic ventricular (tachy-)arrhythmias in patients with heart failure 1.
Overall, amiodarone can be safely used in patients with heart failure, and it does not precipitate heart failure, as supported by the most recent and highest quality study 1.
From the FDA Drug Label
The most important treatment-emergent adverse effects were ... congestive heart failure ...
Other treatment-emergent possibly drug-related adverse events reported in less than 2% of patients receiving amiodarone HCl injection in controlled and uncontrolled studies included the following: ... lung edema ...
Amiodarone can precipitate heart failure. Key points to consider:
- Congestive heart failure is listed as one of the most important treatment-emergent adverse effects.
- Lung edema is also reported as a possible drug-related adverse event. 2 and 2 both support the idea that amiodarone can cause heart failure, although the incidence may be relatively low.
From the Research
Amiodarone and Heart Failure
- Amiodarone is a potent coronary and peripheral vasodilator and can be safely used in patients with left ventricular dysfunction after myocardial infarction or those with congestive heart failure or hypertrophic cardiomyopathy 3.
- The use of amiodarone in patients with heart failure has been studied, and it appears to possess significant antiarrhythmic activity, even in heart failure patients, with proarrhythmia being uncommon 4.
- However, a study found that treatment with amiodarone was associated with an increased risk of death from circulatory failure independent of functional class 5.
- Another study found that amiodarone did not reduce the incidence of sudden death or prolong survival among patients with heart failure, except for a trend toward reduced mortality among those with nonischemic cardiomyopathy 6.
Risks and Side Effects
- Amiodarone has several side effects, including thyroid abnormalities, pulmonary fibrosis, and transaminitis, for which routine monitoring is recommended 7.
- The drug also interacts with several medications, such as warfarin, simvastatin, and atorvastatin, and many HIV antiretroviral medications 7.
- Long-term treatment with amiodarone should be based on the use of minimal doses for satisfactory arrhythmia outcome and serial screening for thyroid, liver, and pulmonary toxicity 3.
Clinical Use
- Amiodarone is generally considered a secondary therapeutic option due to its slow onset of antiarrhythmic action, high risk of non-cardiac toxicity, and common drug-drug interactions 3.
- Patients treated with amiodarone require close supervision by the treating physician 3.
- A thorough understanding of the indications, contraindications, dosing, side effects, and interactions of amiodarone is essential for clinicians to ensure safe and effective use of the medication 7.