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Persistent symptomatic atrial fibrillation: Flecainide - Metoprolol combination reduces atrial fibrillation clinical recurrences and improves tolerability at 1-year follow-up

Atrial fibrillation affects approximately 2% of the total population. In order to prevent atrial fibrillation recurrences, many anti-arrhythmic drugs are currently available, but most of them are burdened by serious side effects and suboptimal efficacy.
The aim of the present study was to test efficacy and safety of a combination of Flecainide and Metoprolol in preventing atrial fibrillation clinical recurrences.

This study is a monocentric, prospective, randomized, open-blinded trial on 173 patients with a recent episode of paroxysmal or persistent atrial fibrillation.
Patients were randomized into group A ( Flecainide plus Metoprolol; n = 80 ), group B ( Flecainide only; n = 72 ), or group C ( Metoprolol only; n = 21 ).

Main exclusion criteria were recent acute coronary syndrome, heart failure NYHA class III-IV, left ventricular ejection fraction less than 0.40, atrioventricular conduction disorders, and severe bradycardia.

Primary endpoint was symptomatic recurrence over 1-year follow-up. Secondary endpoint was quality of life ( QoL ) over 1-year follow-up, as assessed by the SF-36 and Atrial Fibrillation Severity Scale questionnaires.

Combination therapy with Flecainide and Metoprolol significantly reduced recurrences at 1-year follow-up when compared with Flecainide alone in the whole population ( 66.7 vs. 46.8%; P less than 0.001 ) and in patients with persistent atrial fibrillation ( 71.1 vs. 43.6%; P = 0.025 ) while adding beta-blocker therapy to paroxysmal atrial fibrillation showed no benefit over IC anti-arrhythmic drug-only.

Patients randomized to combination therapy experienced a significant improvement of QoL when compared with those assigned to a Flecainide-only regimen irrespective of atrial fibrillation type.

In conclusion, Flecainide-Metoprolol combination therapy improves effectiveness of rhythm control in persistent symptomatic atrial fibrillation and increases tolerability, with a concomitant reduction of side effects and a better compliance. ( Xagena )

Capucci A et al, Europace 2016; Epub ahead of print