Use of Flecainide in Stable Coronary Artery Disease
- The use of flecainide in patients with stable coronary artery disease (both obstructive and nonobstructive) was not associated with an increase in all-cause mortality or ventricular arrhythmias in patients with stable nonobstructive coronary artery disease.
- No increased incidence in mortality was noted based on degree of stenosis, multivessel involvement, or dose of flecainide.
Is flecainide appropriate to use in patients with stable coronary artery disease?
This was a retrospective chart review on all consecutive subjects aged 18 years and older who were prescribed flecainide at a dose of at least 50 mg twice daily for at least 1 year duration at three clinic sites between January 2001 and December 2018. A total of 348 patients underwent coronary angiography and were divided into three groups based on the results: 1) subjects with no or minimal coronary artery disease (CAD) (no stenosis ≥20%); 2) subjects with nonobstructive CAD (defined as >1 stenosis >20% but ≤70%; 3) obstructive CAD (any stenosis >70% or left main stenosis >50%). Patients with structural heart disease, moderate or greater valvular heart disease, no history of myocardial infarction, or creatinine clearance <35mL/min were excluded.
Of the 348 patients evaluated, 196 (56%) had undergone coronary angiography and 152 (44%) underwent stress testing within 3 months of flecainide initiation. The average age was 61.9 years with approximately half of the population being female. The average follow-up time for all patients was 6.3 years (average 4.1 years). The results revealed that the 10-year survival was similar between those with no or minimal CAD, nonobstructive CAD, and obstructive CAD (p = 0.6). There was also no increase in proarrhythmia overall in subjects with no or minimal CAD, nonobstructive CAD, or obstructive CAD (p = 0.44), or between those with and without perfusion defects (p = 1.0). Additionally, on subgroup analysis, there was no increased risk in all-cause mortality related to any specific coronary artery involvement or in those with obstructive multivessel disease (p = 0.89).
The use of flecainide in low-risk patients with stable nonobstructive CAD was not associated with an increase in either all-cause mortality or ventricular arrhythmias.
Current guidelines recommend against the use of flecainide in patients with CAD, left ventricular (LV) dysfunction, or significant structural heart disease. These recommendations are predominately based on the results of the CAST trial. However, the patients in this study were slightly different in that the majority were on flecainide for atrial fibrillation and not ventricular ectopy. More patients in this retrospective study were on beta blockers compared to the CAST trial. Patients with LV dysfunction or structural heart disease were excluded from this study but were included in CAST. The largest difference is that these patients had stable CAD, whereas CAST trial patients had suffered from a myocardial infarction with 2 years of enrollment. Therefore, this patient population was lower risk. The results do raise the question of whether flecainide can be used safely in patients with stable CAD and absence of structural heart disease and risk factors for arrhythmias. Further study is needed to definitively address this question, but flecainide may be an option in carefully selected patients.
Clinical Topics: Arrhythmias and Clinical EP, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Nuclear Imaging, Cardiovascular Care Team, Stable Ischemic Heart Disease
Keywords: Coronary Artery Disease, Coronary Angiography, Atrial Fibrillation, Heart Valve Diseases
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