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Background:The presence of coronary artery disease (CAD) is viewed as a contraindication to use class 1c antiarrhythmic drugs (AAD) due to risk of proarrhythmia, heart failure (HF), and morality. Successful revascularization treats ischemia and in the absence of prior myocardial infarction (MI) may lower the prior risk observed in patients treated with class 1c AADs and severe CAD. Due to concern of risk, long-term data are lacking regarding the use of these medications for atrial fibrillation (AF) or other arrhythmias in patients post revascularization.Methods:From a population of 28,129 patients treated with initiation of AADs for primarily AF, two patient populations were created status post revascularization (percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) based upon AAD class (class III AAD=1,603 and flecainide=150). Patients with an MI, unstable angina, or HF hospitalization within the previous year were excluded. Mortality, HF, ventricular tachycardia (VT), and MACE were assessed at 3 years.Results:The two CAD with revascularization populations treated either with class III AAD and flecainide therapy were similar for age (74.9?9.2 vs 75.5?8.1), male gender (75% versus 70%), hypertension (96% vs 96%), diabetes (46% versus 40%), and ejection fraction (55?14 vs 56?12). In the class III AAD group the most commonly used drugs were amiodarone (64%) and sotalol (25%). At 3 years, mortality and MACE rates were higher in the class III AAD group and HF and VT rates were similar (Figure). Multivariable adjustment for risk with flecainide compared to class IIIc AADs showed a nonsignificant reduction in all endpoints [Hazard ratio: 0.85 (death), 0.89 (HF), 0.72 (VT), and 0.90 (MACE)].Conclusions:Flecainide in patients with severe CAD treated by revascularization with a preserved ejection fraction was associated with favorable risks of death, HF, and proarrhythmia (VT) compared to class IIIc alternatives.

Background:Class 1c antiarrhythmic drugs (AAD) are associated with harm in patients treated for ventricular rhythms with a prior myocardial infarction (MI). Broad exclusion of use of this AAD class to all patients with ventricular arrhythmias in the setting of coronary artery disease (CAD) has been advocated. It is unclear if this exclusion is justified in patients without a prior MI.Methods:From a population of 24,315 patients treated with initiation of AADs, two propensity-matched premature ventricular contraction (PVC) or ventricular tachycardia (VT) patient groups were created with diagnosed CAD based upon AAD class (class III AAD=293 and flecainide=293). Patients with an MI, unstable angina, or HF hospitalization within the previous year were excluded. Outcomes at 3 years for mortality, HF, ventricular tachycardia (VT), and MACE were compared between the groups.Results:Propensity matching for the class III AAD and flecainide groups were similar for age (72.5?12.1 vs 70.5?11.4), hypertension (96% vs 90%), diabetes (41% versus 39%), and ejection fraction (52?11 vs 58?10). In the class III AAD treatment group the most commonly used drugs were amiodarone (66%) and sotalol (20%). The AAD use was in the class III AAD was for PVCs in 91%) and VT in 9%. In contrast, in the flecainide group treatment was for PVCs in 61% and VT in 39% (p<0.0001 in comparison to class III AAD). At 3 years, the multivariate adjusted hazard ratios showed no increased risks with flecainide compared to class III AADs with a significantly reduced risk of mortality (Figure).Conclusions:Flecainide in patients with stable CAD and a preserved ejection for PVCs and VT has a favorable safety profile compared to class III AADs despite flecainide more often used for VT. These data suggest the need for prospective trials of flecainide in CAD patients to determine if the guideline recommended exclusion is justified.