New recommendations for rhythm control—What has changed in the 2023 ACC/AHA/ACCP/HRS and 2024 ESC guidelines for atrial fibrillation, and where does dronedarone fit in?

In recent years, the importance of early rhythm control to delay the progression of atrial fibrillation (AF) has been recognized, as have the benefits of catheter ablation and antiarrhythmic drugs (AADs) as first-line therapy for rhythm control. Selecting the most appropriate AAD according to its safety profile as well as individual patient characteristics is of key importance. To inform decision-making, up-to-date guidelines are paramount. The American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Clinical Pharmacy (ACCP)/Heart Rhythm Society (HRS) guidelines for AF were updated in 2023, while the European Society of Cardiology (ESC) guidelines for AF were updated in 2024. Dronedarone is an AAD indicated in the US to reduce the risk of hospitalization for AF in patients in sinus rhythm with a history of paroxysmal or persistent AF. In Europe, it is indicated for the maintenance of sinus rhythm after successful cardioversion in clinically stable adults with paroxysmal or persistent AF. Since the last major review of the efficacy and safety of dronedarone (published in 2019), multiple real-world evidence (RWE) studies and post hoc analyses of key dronedarone randomized controlled trials have been performed. This review discusses the findings of these RWE studies and post hoc analyses in the context of the 2023 ACC/AHA/ACCP/HRS and 2024 ESC guidelines for AF with a focus on dronedarone as a treatment option for early rhythm control, its use after catheter ablation, and its use in people with heart failure and a mildly reduced or preserved ejection fraction.