Dronedarone has worse outcomes in which subset of heart failure patients, prompting caution in its use?

• A. Permanent atrial fibrillation or severe or recently decompensated heart failure
• B. Hypertension with no cardiac disease
• C. HFrEF with NYHA class I or II
• D. Stable angina without heart failure

Answer: (C)

Dronedarone carries a higher risk in patients with heart failure with reduced ejection fraction. In this group, the drug’s effects can worsen heart muscle function and increase the likelihood of adverse outcomes, such as death or hospitalization for heart failure. This is why clinicians are cautious about using dronedarone in anyone who has HF with reduced EF, even when symptoms are mild (for example, NYHA class II). The Beers Criteria highlights this caution because older adults with HF are particularly vulnerable to harm from this medication.

In contrast, the other scenarios do not involve reduced EF, so the specific HF-related risk isn’t the driving concern in those cases. The key idea is that the subset with heart failure with reduced ejection fraction is where dronedarone has been shown to worsen outcomes, prompting careful use or avoidance.