Reappraising Use of Flecainide for Atrial Fibrillation and Ventricular Arrhythmias in Structural Heart Disease...

Area of Science:

• Cardiology
• Electrophysiology
• Pharmacology

Background:

• Flecainide, a Class Ic antiarrhythmic, was historically contraindicated in structural heart disease (SHD) following the Cardiac Arrhythmia Suppression Trial (CAST).
• Recent data and improved patient selection methods prompt a re-evaluation of flecainide's role in specific SHD populations.

Purpose of the Study:

• To review current evidence on the safety and efficacy of flecainide in treating atrial fibrillation (AF) and premature ventricular contractions (PVCs).
• To assess flecainide's use in patients with stable coronary artery disease (CAD) and arrhythmogenic right ventricular cardiomyopathy (ARVC).

Main Methods:

• Review of recent observational studies and clinical data.
• Evaluation of safety and efficacy endpoints in selected SHD populations.
• Analysis of risk stratification and imaging techniques for patient selection.

Main Results:

• Modern imaging and risk stratification enable precise identification of patients who can safely receive flecainide, even with certain structural abnormalities.
• Observational studies show no increased mortality or ventricular arrhythmias in stable CAD or ARVC patients treated with flecainide under strict criteria.
• Clinical practice is shifting towards a more individualized approach, despite cautious guidelines.

Conclusions:

• Flecainide use in carefully selected SHD patients is feasible and safe, guided by comprehensive imaging and clinical judgment.
• Prospective randomized trials are urgently needed to confirm these findings and potentially update antiarrhythmic therapy guidelines.