Flecainide Toxicity: A Case Report and Systematic Review of its Electrocardiographic Patterns and Management

In the setting of flecainide toxicity, supraventricular tachycardia can manifest as a bizarre right or left bundle branch block, sometimes with a northwest axis, and can easily be mistaken for ventricular tachycardia leading to inappropriate therapy. We conducted a comprehensive literature review for cases of flecainide toxicity. We found 21 articles of flecainide toxicity in adult patients in which 22 ECG tracings were published. In patients with flecainide toxicity and QRS duration ≤ 200 ms, the ECGs were more likely to show RBBB, visible P waves (p = 0.03), and shorter QT (p = 0.02) and QTc intervals (p = 0.004). With QRS duration > 200 ms, the ECGs were more likely to show LBBB, loss of P waves, a northwest axis (p = 0.01), and longer QT and QTc intervals. Deaths were reported only in patients with QRS duration >200 ms, and the outcome of death or requirement for mechanical circulatory support was more prevalent in patients with a QRS duration > 200 ms [2/13 (15.4 %) vs. 6/10 (60 %), p = 0.04]. In patients with access to the medication, flecainide toxicity should be suspected with: (1) broad QRS, (2) RBBB morphology with QRS ≤ 200 ms; RBBB or LBBB morphology with QRS ≥ 200 ms (3) HR out of proportion to the degree of hemodynamic instability. The duration of the QRS interval is prognostic, with mortality and the requirement for mechanical circulatory support being more common in patients with a QRS > 200 ms.