The Safety of 1C Antiarrhythmics in Patients With Coronary Disease

Jul 24, 2023
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Authors:
Kiani S, Sayegh MN, Ibrahim R, et al.
Citation:
The Feasibility and Safety of Flecainide Use Among Patients With Varying Degrees of Coronary Disease. JACC Clin Electrophysiol 2023;9:1172-1180.
Summary By:
Debabrata Mukherjee, MD, FACC

Quick Takes

  • Class 1C agents were independently associated with better event-free survival than class III agents (excluding amiodarone and dronedarone) among patients being treated with antiarrhythmics for atrial fibrillation.
  • Furthermore, although the degree of CAD based clinically was not an independent predictor of event-free survival, there was a significant interaction between 1C use and obstructive CAD, with poorer survival among this group than class III agents.
  • Overall, these data suggest that therapy with a 1C agent may be safe and feasible among patients with nonobstructive CAD in whom they are frequently restricted, and warrants additional prospective studies.

Study Questions:

What is the safety and feasibility of treatment with class 1C antiarrhythmic agents in patients with varying degrees of coronary artery disease (CAD) in a large serial, real-world cohort?

Methods:

The investigators retrospectively identified all patients at their institution from January 2005 to February 2021 on a 1C agent (n = 3,445) and those on sotalol or dofetilide (n = 2,216) as controls, excluding those with a prior history of ventricular tachycardia, implantable cardioverter-defibrillator placement, or nonrevascularized myocardial infarction. Baseline clinical characteristics included degree of CAD (categorized as none, nonobstructive, or obstructive), other comorbid illness, and medication use. Clinical outcomes, including survival, were ascertained. The authors performed Cox regression analysis to evaluate the effect of 1C use on event-free survival across varying degrees of CAD.

Results:

After adjustment for baseline characteristics, there was an independent association between 1C use and improved mortality. However, there was an interaction between 1C use and degree of CAD (compared to sotalol) demonstrating poorer event-free survival among those with obstructive coronary disease (hazard ratio, 3.80; 95% confidence interval, 1.67-8.67; p = 0.002).

Conclusions:

The authors report that among select patients with nonobstructive CAD and without a history of ventricular tachycardia, 1C agents are not associated with increased mortality.

Perspective:

This real-world study of patients being treated with an antiarrhythmic drug for atrial fibrillation reports that class 1C agents were independently associated with better event-free survival than class III agents (excluding amiodarone and dronedarone). Furthermore, although the degree of CAD based clinically was not an independent predictor of event-free survival, there was a significant interaction between 1C use and obstructive CAD, with poorer survival among this group than those on class III agents. Overall, these data suggest that therapy with a 1C agent may be safe and feasible among patients with nonobstructive CAD in whom they are frequently restricted, and warrants additional prospective studies.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Prevention, Atherosclerotic Disease (CAD/PAD), Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Anti-Arrhythmia Agents, Arrhythmias, Cardiac, Atrial Fibrillation, Coronary Artery Disease, Flecainide, Heart Failure, Myocardial Infarction, Myocardial Ischemia, Secondary Prevention, Survival, Tachycardia, Ventricular


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