Long-term outcomes in patients treated with flecainide for atrial fibrillation with stable coronary artery disease.

Background: 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 (AF) in patients with CAD without a prior myocardial infarction.
Methods: In 24,315 patients treated with the initiation of AADs, two populations were evaluated: (1) propensity-matched AF patients with CAD were created based upon AAD class (flecainide, n = 1,114, vs class-3 AAD, n = 1,114) and (2) AF patients who had undergone a percutaneous coronary intervention or coronary artery bypass graft (flecainide, n = 150, and class-3 AAD, n = 1,453). Outcomes at 3 years for mortality, heart failure (HF) hospitalization, ventricular tachycardia (VT), and MACE were compared between the groups.
Results: At 3 years, mortality (9.1% vs 19.3%, P < .0001), HF hospitalization (12.5% vs 18.3%, P < .0001), MACE (22.9% vs 36.6%, P < .0001), and VT (5.8% vs 8.5%, P = .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 AAD group for mortality (20.9% vs 25.8%, P = .26), HF hospitalization (24.5% vs 26.1%, P = .73), VT (10.9% vs 14.7%, P = .28) and MACE (44.5% vs 49.5%, P = .32).
Conclusions: Flecainide in select patients with stable CAD for AF has a favorable safety profile compared to class-3 AADs. These data suggest the need for prospective trials of flecainide in AF patients with CAD to determine if the current guideline-recommended exclusion is warranted.
Competing Interests: Declaration of Competing Interest Benjamin Steinberg receives support from the National Heart, Lung, And Blood Institute of the National Institutes of Health (#K23HL143156), and reports research support from Abbott, Boston Scientific, and Janssen; and consulting to Janssen, AltaThera, Merit Medical, and Bayer; and speaking for NACCME (funded by Sanofi). Ravi Ranjan is supported by NIH R01 HL142913. Ravi Fanjan also has or has had recent research grants from Biosense Webster and Abbott and is a consultant to Abbott and Biosense Webster. John Day has consulted with Abbott Medical and Boston Scientific. T. Jared Bunch MD has received research grants: Boehringer Ingelheim, Boston Scientific, Altathera. All others report no conflicts of interest relevant to this study.
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