Flecainide atrial fibrillation
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Flecainide in the Treatment of Atrial Fibrillation: Efficacy, Mechanisms, and Safety
Introduction to Flecainide and Atrial Fibrillation
Atrial fibrillation (AF) is the most common sustained arrhythmia, significantly impacting patients' quality of life and increasing morbidity. Flecainide, a Class Ic antiarrhythmic drug, has been extensively studied for its efficacy in treating AF, particularly in patients without structural heart disease2 7.
Mechanism of Action: Flecainide in Atrial Fibrillation
Flecainide's antiarrhythmic action in AF is primarily due to its ability to increase atrial effective refractory period (ERP) and reduce conduction velocity in a tachycardia-dependent manner. This results in an increased wavelength, which prevents the reentry circuits that sustain AF1. Flecainide also reduces regional heterogeneity in ERP and wavelength, counteracting the effects of vagal stimulation1.
Clinical Efficacy of Flecainide
Acute Conversion to Sinus Rhythm
Flecainide has demonstrated high efficacy in the acute conversion of recent-onset AF to sinus rhythm. In a study comparing flecainide with amiodarone and placebo, flecainide achieved conversion to sinus rhythm in 91% of patients within 8 hours, significantly outperforming both amiodarone and placebo3. Another study confirmed that both oral and intravenous flecainide are effective for acute conversion, particularly in patients with recent-onset AF5.
Long-term Maintenance of Sinus Rhythm
For the chronic suppression of paroxysmal and persistent AF, flecainide has shown moderate effectiveness, comparable to other antiarrhythmic drugs except amiodarone2. In a multicenter study, flecainide significantly reduced the number of symptomatic recurrences of paroxysmal AF, with a notable reduction in the frequency of attacks and an increase in the time interval between episodes6.
Combination Therapy
Combining flecainide with metoprolol has been found to further reduce AF recurrences and improve tolerability. This combination therapy was more effective than flecainide alone in preventing symptomatic recurrences over a one-year follow-up period, particularly in patients with persistent AF4.
Safety Profile of Flecainide
General Safety
Flecainide is generally safe and well-tolerated in patients without structural heart disease. Despite initial concerns from the Cardiac Arrhythmia Suppression Trial (CAST) about increased mortality, subsequent studies have shown that flecainide has a favorable safety profile in appropriate patient populations2 7.
Adverse Effects
While flecainide is effective, it is associated with some adverse effects. In a study on the prevention of paroxysmal AF, 74% of patients reported adverse effects, though most were tolerable, and only a few led to withdrawal from the study8. Serious adverse effects, including proarrhythmia, are rare but necessitate careful patient selection and monitoring9.
Conclusion
Flecainide is a potent antiarrhythmic agent for the treatment of atrial fibrillation, particularly effective in acute conversion and long-term maintenance of sinus rhythm in patients without structural heart disease. Its mechanism of action involves increasing atrial ERP and reducing conduction velocity, thereby preventing reentry circuits. While generally safe, flecainide should be used with caution, considering its potential adverse effects. Combination therapy with beta-blockers like metoprolol can enhance its efficacy and tolerability, offering a valuable treatment option for managing AF.
Sources and full results
Most relevant research papers on this topic
Mechanism of flecainide's antiarrhythmic action in experimental atrial fibrillation.
Flecainide effectively terminates atrial fibrillation in an experimental model by causing tachycardia-dependent increases in atrial action potential duration, increasing the wavelength to a point where the arrhythmia can no longer sustain itself.
RCT
Animal Study
Highly CitedUse of Flecainide for the Treatment of Atrial Fibrillation.
Flecainide is an effective and safe first-line treatment for atrial fibrillation in patients without structural heart disease, but its use has been curtailed due to concerns about ventricular proarrhythmia.
Effectiveness of loading oral flecainide for converting recent-onset atrial fibrillation to sinus rhythm in patients without organic heart disease or with only systemic hypertension.
Loading oral flecainide effectively converts recent-onset atrial fibrillation to sinus rhythm in patients without organic heart disease or systemic hypertension, with shorter conversion times than amiodarone.
RCTHighly CitedFlecainide-metoprolol combination reduces atrial fibrillation clinical recurrences and improves tolerability at 1-year follow-up in persistent symptomatic atrial fibrillation.
Flecainide-metoprolol combination therapy effectively reduces atrial fibrillation recurrences and improves tolerability, with reduced side effects and better compliance.
RCTAcute conversion of atrial fibrillation to sinus rhythm: clinical efficacy of flecainide acetate. Comparison of two regimens.
Oral and intravenous regimens of flecainide acetate effectively and safely convert recent onset atrial fibrillation to sinus rhythm in patients without serious adverse effects.
RCTHighly CitedPrevention of symptomatic recurrences of paroxysmal atrial fibrillation in patients initially tolerating antiarrhythmic therapy. A multicenter, double-blind, crossover study of flecainide and placebo with transtelephonic monitoring. Flecainide Supraventricular Tachycardia Study Group.
Flecainide effectively reduces symptomatic recurrences of paroxysmal atrial fibrillation in patients initially tolerating antiarrhythmic therapy, with transtelephonic monitoring providing valuable data for outpatient therapy assessment.
RCTHighly CitedTwenty-five years in the making: flecainide is safe and effective for the management of atrial fibrillation
Flecainide is a safe and effective first-line treatment for restoring and maintaining sinus rhythm in patients with atrial fibrillation without significant left ventricular disease or coronary heart disease.
Literature ReviewHighly CitedUsefulness of flecainide for prevention of paroxysmal atrial fibrillation and flutter. Danish-Norwegian Flecainide Multicenter Study Group.
Flecainide significantly reduced the number of attacks of paroxysmal atrial fibrillation and flutter, with frequent but mostly tolerable adverse effects.
RCTHighly CitedEfficacy and safety of flecainide acetate in the maintenance of sinus rhythm after electrical cardioversion of chronic atrial fibrillation or atrial flutter.
Flecainide may effectively postpone arrhythmia recurrence after electrical cardioversion for chronic atrial fibrillation or atrial flutter, with low incidence of ventricular proarrhythmia.
RCTHighly CitedFlecainide acetate treatment of paroxysmal supraventricular tachycardia and paroxysmal atrial fibrillation: dose-response studies. The Flecainide Supraventricular Tachycardia Study Group.
Flecainide acetate effectively reduces recurrent tachycardia in patients with paroxysmal supraventricular tachycardia and paroxysmal atrial fibrillation, with higher doses yielding greater benefits.
RCTHighly Cited