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 in patients with coronary artery disease without a prior myocardial infarction.
In 24,315 patients treated with the initiation of antiarrhythmic drugs, two populations were evaluated: (1) propensity-matched atrial fibrillation patients with coronary artery disease were created based upon AAD class ( Flecainide, n = 1,114, vs class-3 antiarrhythmic drugs, n = 1,114 ) and ( 2 ) atrial fibrillation patients who had undergone a percutaneous coronary intervention or coronary artery bypass graft ( Flecainide, n = 150, and class-3 antiarrhythmic drugs, n = 1,453 ).
Outcomes at 3 years for mortality, heart failure hospitalization, ventricular tachycardia, and major adverse cardiovascular events ( MACE ) were compared between the groups.
At 3 years, mortality ( 9.1% vs 19.3%, P less than 0.0001 ), heart failure hospitalization ( 12.5% vs 18.3%, P less than 0.0001 ), MACE ( 22.9% vs 36.6%, P less than 0.0001 ), and ventricular tachycardia ( 5.8% vs 8.5%, P = 0.02 ) 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 antiarrhythmic drugs group for mortality ( 20.9% vs 25.8%, P = 0.26 ), heart failure hospitalization ( 24.5% vs 26.1%, P = 0.73 ), ventricular tachycardia ( 10.9% vs 14.7%, P = 0.28 ) and MACE ( 44.5% vs 49.5%, P = 0.32 ).
In conclusion, Flecainide in select patients with stable coronary artery disease for atrial fibrillation has a favorable safety profile compared to class-3 antiarrhythmic drugs.
These data suggest the need for prospective trials of Flecainide in atrial fibrillation patients with coronary artery disease to determine if the current guideline-recommended exclusion is warranted. ( Xagena )
Burnham TS et al, Am Heart J 2022; 243: 127-139