Vernakalant Description

1. BRINAVESS™
For rapid conversion of
recent-onset atrial fibrillation

2. ESC 2016 AF Guidelines recommend
conversion of recent-onset AF
Kirchhof et al. European Heart Journal. (2016) 37, 2893-2962

3. Prompt cardioversion of AF is associated
with increased success rates
1. Reisinger J et al. Eur Heart J. 2004;25:1318-24. 2. Ricard P et al. Am J Cardiol. 1997;79:815-16.
%
Conversion
to
NSR
Duration of AF at time of treatment
98%
62%
0
20
40
60
80
100
1 - 24 h 24 - 48 h
Study 11 Study 22
61%
41%
0
20
40
60
80
100
1 - 24 h 24 - 48 h
Flecainide (IV) DC Cardioversion
(Paddle/Patch; ≤ 200 J)
n=79 n=22 n=66 n=132
Duration of AF at time of treatment
%
Conversion
to
NSR
p<0.001
p value not reported

4. Nuotio I, Hartikainen JK, Grönberg T, et al. Time to cardioversion for acute atrial fibrillation and thromboembolic complications. JAMA 2014; 312:647-649
0,7%
1,1%
0,3%
0
1
2
3
< 48 hours
(Overall results)
12-48 hours <12 hours
p=0.004
Time from symptom onset to cardioversion
Thromboembolic
Complications
%
Finnish CardioVersion Study (n=5116)
Prompt cardioversion is associated with
lower risk of stroke/TIA within 30 days

5. Antiarrhythmic Drug Classes
Amiodarone and dronedarone have also class I, II and IV activity
Sotalol has also class II activity
EU Summary of Product Characteristics, BRINAVESS, 8.8.2018
Adapted from Penttilä et al Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2017 25:81. https://doi.org/10.1186/s13049-017-0424-7
Class I
(Na +
channel blockers)
Lidocaine
Flecainide
Propafenone
Quinidine
Vernakalant
Class II
( b blockers)
Atenolol
Metoprolol
Carvedilol
Class III
(K +
channel blockers)
Amiodarone
Ibutilide
Sotalol
Dronedarone
Vernakalant
Class IV
(Ca
2+
channel blockers)
Verapamil
Diltiazem
Channel
blockers

6. Atrium
Ventricle
IKur IK-Ach
K+-Ion current inhibition by BRINAVESS™ :
Some are present only in the atria
Ito IK(ATP)
IKr IKs IK1
Ravens U et al. Europace. 2008;10:1133–1137.
AP=Action potential; Ito = transient outward current; IKur = ultrarapid delayed-rectifier potassium current; IKr = rapid
delayed-rectifier potassium current; IKs = slow delayed-rectifier potassium current; IK1 = inward rectifier potassium
current; IK-Ach = acetylcholine-regulated potassium current; IK(ATP) = ATP-sensitive potassium current.
IK-Ach
Atrial AP
IKur
IKr
IKs
IK1
Ito1
Ito1
IKr
IKs
IK1 IKATP
Ventricular AP
IKATP
Ito IK(ATP)
IKr IKs IK1

7. ATRIUM
600-1000 BPM
VENTRICLE
100-160 BPM
Normal
AF
During BRINAVESS™
infusion
INA
ITO
IACH
During BRINAVESS™
infusion
Shortened Refractory Period
IKUR
IKR
Prolongation of Refractory Period
Minor prolongation of Refractory Period
(QRS & QT)
Conceptual mode of action during AF
Late INA
ITO
IKR
D. Fedida. Expert Opin. lnvestig. Drugs (2001) 16(4):519-532,
EU Summary of Product Characteristics, BRINAVESS, 8.8.2018; Roy D et al. Circulation. 2008;117:1518–1525

8. AF = atrial fibrillation; QTcB = Bazett-corrected QT interval; QTcF = Fridericia-corrected QT interval; ms = milliseconds.
aData for responders were not presented.
Mean QTcB and QTcF Changes Over 2 Hours Postdose1
BRINAVESS™ has minor and
transient impact on QT interval
1. Pratt CM et al. Am J Cardiol 2010;106:1277–1283.

9. Administration
1 Vial (25 ml) 100 ml Solution
10 Min infusion of 3 mg/kg
If no conversion within 15
minutes after the end of
the first infusion, a 2nd
10 min infusion of 2 mg/kg
may be administered *
EU Summary of Product Characteristics, BRINAVESS, 8.8.2018.
For patients weighing ≥ 113 kg, the maximum initial dose of 339 mg and the
maximum second infusion of 226 mg should not be exceeded. Cumulative
doses of greater than 5 mg/kg should not be administered within 24 hours.

10. Pre infusion checklist in each pack
BRINAVESS package insert

11. Treatment-Related Adverse Reactions
Within 24 Hours of Administration
Very common ( ≥1/10)
Dysgeusia (16%)
Sneezing (12.5%)
Common ( ≥1/100 to <1/10)
Paraesthesia (6.9%), Dizziness, Headache,
Hypoaesthesia
Bradycardia, Atrial flutter
Hypotension
Cough, Nasal discomfort
Nausea, Vomiting, Paraesthesia oral
Pruritus, Hyperhidrosis
Infusion site pain, Feeling hot
EU Summary of Product Characteristics, BRINAVESS, 8.8.2018.

12. Warnings and Precautions
During infusion of vernakalant, if patients develop
 A sudden drop in blood pressure or heart rate, with or without
symptomatic hypotension or bradycardia
 Clinically meaningful bradycardia
 Hypotension
 ECG changes such as
– Clinically meaningful sinus pause, complete heart block, new bundle
branch block, significant prolongation of the QRS or QT interval
– Changes consistent with ischaemia or infarction
– Ventricular arrhythmia
then the administration of vernakalant should be discontinued
– These patients should receive appropriate medical management
– If these events occur during the 1
st
infusion, patients should not
receive the 2
nd
dose of vernakalant
EU Summary of Product Characteristics, BRINAVESS, 8.8.2018.

13. Warnings and Precautions
 Vital signs and cardiac rhythm should be monitored for 2 hours after
the start of vernakalant infusion until clinical and ECG parameters have
stabilised
 Blood pressure should also be monitored during and at least
15 minutes after the completion of the infusion
 Direct-current cardioversion may be considered for patients who do not
respond to therapy, but no clinical experience under
2 hours postdose
 Prior to attempting pharmacological cardioversion
– Patients should be adequately hydrated and haemodynamically optimized
– Patients should be anticoagulated in accordance with guidelines
– Serum potassium levels <3.5 mmol/l should be corrected
EU Summary of Product Characteristics, BRINAVESS, 8.8.2018.

14. Warnings and Precautions
Valvular Heart Disease
 Higher incidence of ventricular arrhythmia events with vernakalant and
these patients should be monitored closely
Other Diseases and Conditions Not Studied
 Vernakalant has been administered to patients with an uncorrected QT
less than 440 msec without an increased risk of torsade de pointes.
 Furthermore, vernakalant has not been evaluated in patients with clinically
meaningful valvular stenosis, hypertrophic obstructive cardiomyopathy,
restrictive cardiomyopathy, or constrictive pericarditis and its use can not
be recommended in such cases. There is limited experience with
vernakalant in patients with pacemakers.
 As the clinical trial experience in patients with advanced hepatic
impairment is limited, vernakalant is
not recommended in these patients
EU Summary of Product Characteristics, BRINAVESS, 8.8.2018.

15. Warnings and Precautions
Hypotension
 Hypotension can occur in a small number of patients
(vernakalant 7.6%, placebo 5.1%).
 Hypotension typically occurs early, either during the infusion or early
after the end of the infusion, and can usually be corrected by standard
supportive measures.
 Uncommonly, cases of severe hypotension have been observed.
Patients with congestive heart failure (CHF) have been identified as a
population at higher risk for hypotension. (See section 4.8.)
 The patient is required to be monitored for signs and symptoms of a
sudden decrease in blood pressure or heart rate for the duration of the
infusion and for at least 15 minutes after the completion of the infusion.
EU Summary of Product Characteristics, BRINAVESS, 8.8.2018.

16. Warnings and Precautions
Congestive Heart Failure
 The incidence of hypotensive events within the first 2 hours after dosing
was more common with vernakalant in patients with CHF (vs. placebo)
– No significant difference in hypotension was seen in patients without CHF
– Hypotension was reported as a serious adverse event or led to
discontinuation more frequently in patients with CHF receiving vernakalant
compared to placebo (2.9% vs. 0%)
 The incidence of ventricular arrhythmia (VA) in the first 2 hours post dose
was more common with vernakalant in patients with CHF (vs. placebo)
– No increase in VA with vernakalant was seen in patients without CHF
 Vernakalant should be used cautiously in haemodynamically stable
patients with CHF functional classes New York Heart Association
(NYHA) I to II (contraindicated in NYHA III or IV)
 Experience in patients with left ventricular
ejection fraction ≤35% is limited and use of
vernakalant in these patients is not recommended
EU Summary of Product Characteristics, BRINAVESS, 8.8.2018.

17. Warnings and Precautions
Atrial Flutter
 BRINAVESS was not found to be effective in converting typical
primary atrial flutter to sinus rhythm.
 Patients receiving BRINAVESS have a higher incidence of
converting to atrial flutter within the first 2 hours post-dose. This risk
is higher in patients who use Class I antiarrhythmics (see section
4.8).
 If atrial flutter is observed as secondary to treatment, continuation of
infusion should be considered (see section 4.2).
 In post-marketing experience very rare cases of atrial flutter with
1:1-atrioventricular conduction are observed.
EU Summary of Product Characteristics, BRINAVESS, 8.8.2018.

18. Warnings and Precautions
Use of anti-arrhythmic Drugs (AAD)
prior to or after BRINAVESS™
 Intravenous (IV) AADs (Class I, III)
– Vernakalant is not recommended if IV AADs were given within previous
4-24 hours (lack of data)
– Vernakalant should not be administered to patients who received IV AADs
within 4 hours prior to vernakalant
– IV AADs should not be used in first 4 hours after vernakalant infusion
(limited experience)
 Oral AADs (class I, III)
– Vernakalant should be used with caution in patients on oral AADs (limited
experience).
– Resumption or initiation of oral maintenance AAD can be considered
2 hours after vernakalant administration
EU Summary of Product Characteristics, BRINAVESS, 8.8.2018.

19. Approved indications in EU
Rapid conversion of recent-onset AF
to sinus rhythm in adults
• For non-surgery patients:
AF ≤7 days duration
• For post-cardiac surgery patients:
AF ≤3 days duration
EU Summary of Product Characteristics, BRINAVESS, 8.8.2018.

20. Contraindications
• Hypersensitivity to the active substance or to any of the excipients listed
in section 6.1.
• Patients with severe aortic stenosis, patients with systolic blood pressure
< 100 mm Hg, and patients with heart failure class NYHA III and IV.
• Patients with prolonged QT at baseline (uncorrected > 440 msec), or
severe bradycardia, sinus node dysfunction or second degree and third
degree heart block in the absence of a pacemaker.
• Use of intravenous rhythm control antiarrhythmics (class I and class III)
within 4 hours prior to, as well as in the first 4 hours after, BRINAVESS
administration.
• Acute coronary syndrome (including myocardial infarction)
within the last 30 days.

21. Study Population
(AF/AFL Duration)
Design
Number of Patients
Vernakalant Placebo/Control
ACT I 1 3 hours–45 days
Randomized, double-blind,
placebo-controlled
221 115
ACT III 2 3 hours–45 days
Randomized, double-blind,
placebo-controlled
134
(AFL: N=14)
131 (AFL: N=9)
ACT II 3
Post-cardiac surgery
3–72 hours
Randomized, double-blind,
placebo-controlled
107
(AFL: N=7)
54
(AFL: N=4)
ACT IV 4 3 hours–45 days Open-label 236
ACT V 6 3 hours–7 days
Randomized, double-blind,
placebo-controlled
145 72
Asia-Pacific 7 3 hours–7 days
Randomized, double-blind,
placebo-controlled
55 56
AVRO 5 3 hours–48 hours
Randomized, double-blind,
active-controlled with amiodarone
116 116 (amiodarone)
Phase III Clinical Program
1. Roy D et al. Circulation. 2008;117:1518–1525; 2. Pratt CM et al. Am J Cardiol. 2010;106:1277–1283;
3. Kowey PR et al. Circ Arrhythmia Electrophysiol. 2009;2:652–659; 4. Stiell IG et al. Am Heart J.
2010;159:1095–1101; 5. Camm AJ et al. J Am Coll Cardiol. 2011;57:313–321. 6. Beatch et al BMC Cardiovasc
Disord. 2016; 28;16:1137. 7. Beatch et al. J Cardiovasc Pharmacol. 2017; 69(2):86-92
Clinical Trials
AFL = atrial flutter

22. Primary Endpoint:
Converted to SR within 90 Min
51.7 51.2
45.7
52.7 51.0 51.7
47.0
4.0 3.6
1.5
12.5
5.2
14.0
0
10
20
30
40
50
60
70
80
90
100
BRINAVESS™ Placebo/Control
%
AF
Termination
within
90
minutes
p<0.001 p<0.001 p<0.001 p<0.001
Clinical Trials
Median time to cardioversion: 8 – 14 minutes
ACT I1 ACT III2 ACT IV4 AVRO5 ACT II3
ACT V6 Asia-Pacific7
p<0.001
p<0.0001 p N/A
1. Roy D et al. Circulation. 2008;117:1518–1525; 2. Pratt CM et al. Am J Cardiol. 2010;106:1277–1283;
3. Kowey PR et al. Circ Arrhythmia Electrophysiol. 2009;2:652–659; 4. Stiell IG et al. Am Heart J.
2010;159:1095–1101; 5. Camm AJ et al. J Am Coll Cardiol. 2011;57:313–321. 6. Beatch et al BMC Cardiovasc
Disord. 2016; 28;16:1137. 7. Beatch et al. J Cardiovasc Pharmacol. 2017; 69(2):86-92
Post
Cardiac Surgery
Data from ACT trials show evaluation for patients with AF ≤ 7 days

23. 1. ACT 1 Roy D et al. Circulation. 2008;117:1518–1525. 2. ACT III Pratt CM et al. Am J Cardiol. 2010;106:1277–
1283. 3. ACT I and III pooled Brinavess Assessment report EMA2 011. www.emea.eu 4. ACT IV Stiell_Am
Heart J 2010;159:1095-1101 5. Asia-Pacific J Cardiovasc Pharmacol. 2017 Feb;69(2):86-92.
97
93
98
89
89
82
0
20
40
60
80
100
24 h 7 d
%
Patients
in
Sinus
Rhythm
Time after Cardioversion
ACT I and ACT III pooled ACT IV Asia-Pacific
Maintenance of sinus rhythm after
cardioversion with BRINAVESS™
Clinical Trials

24. 1: PACE 2015;38(2):196-200; 2: Eur J Cardiovasc Med, 2013;2(4) 226-233. 3: 7.9.2018 / AKH Wien
(7. Notfallsymposium) 4: Eur Heart J Acute Cardiovasc Care. 2017 Aug 1: 2048872617728558;
5: Ir J Med Sci. 2017 Nov;186(4):903-908 6: Wiener Klinische Wochenschrift 2014 126:2 SUPPL.1 (S105-S106).
7: Emergencias 2017;29:397-402
85
70 72
68
83
61
78
0
10
20
30
40
50
60
70
80
90
100
%
Conversion
to
SR
B. Aires
Argentina 1
n=121
Malmö
Sweden 2
n=355
Kuopio,
Finland 4
n=100
Real world experience
Dublin,
Ireland 5
n=42
Linz,
Austria 6
n=61
Valencia,
Spain 7
n=165
Vienna,
Austria 3
n=230
Post marketing registries with
BRINAVESS™
Mean
AF duration: 4 hours 6.5 hours Not reported 11 hours 12 hours 21 hours 78% <12 hours

25. BRINAVESS™ vs. comparators
in patients with AF <48 hours
51.7
69.0 68.0
5.2
43.0
47.0
0
10
20
30
40
50
60
70
80
90
100
BRINAVESS Amiodarone BRINAVESS Ibutilide BRINAVESS Flecainide
%
AF
Termination
within
90
minutes
p<0.001
Randomized
study1
(n=232)
Randomized
study2
(n=100)
Non randomized
study3
(n=200)
p=0.01 p=0.003
Conversion within 90 Minutes
1. Camm AJ et al. J Am Coll Cardiol. 2011;57:313–321. 2. Simon et al. Europace. 2017 Feb 1; 19(2):233-240
3. H P PohjantahtiMaaroos et al. EHJ: Acute Cardiovascular Care (2015) 4 (supplement 5), S211

26. 1: Carbajosa Dalmau J, et al. Emergencias 2017;29:397-402; 2: PACE 2015;38(2):196-200
3: Eur J Cardiovasc Med, 2013;2(4) 226-233 4: A.E. Heikkola et al. European Heart Journal (2017) 38 ( Supplement ), 782
4.5
2.8
6.5
8.8
0
2
4
6
8
10
12
Time
in
Emergency
Department
(hours)
Costabel
Argentina 2
n=121
Juul-Möller
Sweden 3
n=355
Real world experience
Carbajosa
Spain 1
n=165
BRINAVESS™ may facilitate early
discharge from Emergency Department
Heikkola,
Finland 4
n=100

27. Avoidance of hospitalization
for more than 80% of patients
97 patients treated with BRINAVESS™ for recent-onset AF in the
ER across 6 participating centres in Belgium.
Total Mean
95% CI
LL UL
Total patients treated 97
Number of patients
without electric cardioversion
79 81.4%
Mean ratio of the 6 centers 84.1% 71.5% 96.7%
Number of patients
without hospitalization
79 81.4%
Mean ratio of the 6 centers 85.4% 76.1% 94.8%
CI = Confidence Interval, LL = lower limit, UL = upper limit
Data on file Correvio;;Accepted Poster Belgian Society of Cardiology Annual Meeting February 2019
Real world experience

28. Summary
 BRINAVESS™ is a relatively atrial-specific short acting, intravenous
antiarrhythmic drug for rapid conversion (10-15 min median time) of
atrial fibrillation
 Most common side effects are dysgeusia and sneezing
 ~ 50% cardioversion success in phase 3 trials (AF <7 days)
 ~ 70% cardioversion success in post-marketing studies (AF <48h)
 BRINAVESS™ is superior to Amiodarone IV and Ibutilide1, 2
 BRINAVESS™ offers the potential to discharge patients from ER or
hospital within few hours after admission
1. Camm AJ et al. J Am Coll Cardiol. 2011;57:313–321. 2. Simon et al. Europace. 2017 Feb 1; 19(2):233-240