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Pill-in-the-Pocket Antiarrhythmic Drug for Atrial Fibrillation
Quick Takes
- In a cohort of 273 patients using a pill-in-the-pocket antiarrhythmic drug to terminate atrial fibrillation, there were rare (3%), but significant adverse events: unexplained syncope (1 of 7), symptomatic bradycardia/hypotension (4 of 7), and 1:1 atrial flutter (2 of 7). All occurred in patients taking 300 mg of flecainide (n = 4) or 600 mg of propafenone (n = 3).
- Prospective studies are needed to evaluate the safety and efficacy of lower-dose pill-in-the-pocket Class 1C antiarrhythmic drugs and whether they can be safely initiated in an unmonitored setting.
Study Questions:
What is the real-world, contemporary use of the pill-in-the-pocket approach, including the setting of initiation and incidence of adverse events?
Methods:
This was a retrospective cohort study of all patients at the Hospital of the University of Pennsylvania treated with a pill-in-the-pocket approach for atrial fibrillation (AF) between 2007 and 2020.
Results:
A total of 273 patients (mean age, 56 years; 67% male) were analyzed. Flecainide was used in 55% and propafenone in 45% of patients. The first dose was taken in a monitored setting in 62% of the cohort. Significant adverse events occurred in 7 patients (3%), 2 of whom had taken the dose in the monitored setting. Significant adverse events included unexplained syncope (1 of 7), symptomatic bradycardia/hypotension (4 of 7), and 1:1 atrial flutter (2 of 7). All occurred in patients taking 300 mg of flecainide (n = 4) or 600 mg of propafenone (n = 3). Electrical cardioversion was performed in 11% of patients because of failure of the antiarrhythmic drug to terminate AF. One patient required intravenous fluids and vasopressors for 2 hours because of persistent hypotension and bradycardia. Two patients required permanent pacemakers for bradycardia.
Conclusions:
The authors concluded that their data support the current recommendation to initiate pill-in-the-pocket Class 1C antiarrhythmic drugs in a monitored setting because of rare significant adverse reactions.
Perspective:
Current guidelines recommend that the first administration of the Class 1C antiarrhythmic pill-in-the-pocket be done in a monitored setting. Their agents should only be used in patients without structural heart disease. Clinical trials have shown that treatment with 300 mg of flecainide and 600 mg of propafenone may convert up to 40% of patients with AF. Due to cost and logistical considerations, in real-life practice, many patients are asked to initiate this treatment at home. The present study shows that while the rate of adverse events is low at about 3-4%, they are often very significant. The authors were not able to identify factors predictive of adverse events. All patients with adverse events were taking a high dose of flecainide or propafenone in this study. It is possible that lower doses may be safer and still offer a comparable conversion rate, and this should be investigated in future studies.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Anti-Arrhythmia Agents, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Atrial Flutter, Bradycardia, Electric Countershock, Flecainide, Hypotension, Pacemaker, Artificial, Propafenone, Syncope
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