Long-term outcomes in patients treated with flecainide for atrial fibrillation with stable coronary artery disease

• Published in: The American heart journal 2022-01, Vol.243, p.127-139
• Main Authors: Burnham, Tyson S., May, Heidi T., Bair, Tami L., Anderson, Jeffrey A., Crandall, Brian G., Cutler, Michael J., Day, John D., Freedman, Roger A., Knowlton, Kirk U., Muhlestein, Joseph B., Navaravong, Leenhapong, Ranjan, Ravi A., Steinberg, Benjamin A., Bunch, T. Jared
• Format: Article
• Language: English
• Subjects: Adverse events; Anti-Arrhythmia Agents - therapeutic use; Antiarrhythmics; Arrhythmia; Atrial Fibrillation - complications; Atrial Fibrillation - drug therapy; Cardiac arrhythmia; Cardiovascular disease; Chronic obstructive pulmonary disease; Clinical trials; Codes; Congestive heart failure; Coronary artery; Coronary artery disease; Coronary Artery Disease - complications; Coronary Artery Disease - drug therapy; Coronary vessels; Drug dosages; Drugs; Electrocardiography; Fibrillation; Flecainide - therapeutic use; Health care policy; Heart; Heart surgery; Hospitalization; Humans; Immunosuppressive agents; Mortality; Myocardial infarction; Patients; Prospective Studies; Tachycardia; Vein & artery diseases; Ventricle
• ISSN: 0002-8703; 1097-6744
• DOI: 10.1016/j.ahj.2021.08.013

Class 1C antiarrhythmic drugs (AAD) have been associated with harm in patients treated for ventricular arrhythmias with a prior myocardial infarction. Consensus guidelines have advocated that these drugs not be used in patients with stable coronary artery disease (CAD). However, long-term data are lacking to know if unique risks exist when these drugs are used for atrial fibrillation (AF) in patients with CAD without a prior myocardial infarction. In 24,315 patients treated with the initiation of AADs, two populations were evaluated: (1) propensity-matched AF patients with CAD were created based upon AAD class (flecainide, n = 1,114, vs class-3 AAD, n = 1,114) and (2) AF patients who had undergone a percutaneous coronary intervention or coronary artery bypass graft (flecainide, n = 150, and class-3 AAD, n = 1,453). Outcomes at 3 years for mortality, heart failure (HF) hospitalization, ventricular tachycardia (VT), and MACE were compared between the groups. At 3 years, mortality (9.1% vs 19.3%, P < .0001), HF hospitalization (12.5% vs 18.3%, P < .0001), MACE (22.9% vs 36.6%, P < .0001), and VT (5.8% vs 8.5%, P = .02) rates were significantly lower in the flecainide group for population 1. In population 2, adverse event rates were also lower, although not significantly, in the flecainide compared to the class-3 AAD group for mortality (20.9% vs 25.8%, P = .26), HF hospitalization (24.5% vs 26.1%, P = .73), VT (10.9% vs 14.7%, P = .28) and MACE (44.5% vs 49.5%, P = .32). Flecainide in select patients with stable CAD for AF has a favorable safety profile compared to class-3 AADs. These data suggest the need for prospective trials of flecainide in AF patients with CAD to determine if the current guideline-recommended exclusion is warranted. [Display omitted] .