Twenty-five years in the making: flecainide is safe and effective for the management of atrial fibrillation

Etienne Aliot, Alessandro Capucci, Harry J Crijns, Andreas Goette, Juan Tamargo, Etienne Aliot, Alessandro Capucci, Harry J Crijns, Andreas Goette, Juan Tamargo

Abstract

Atrial fibrillation (AF) is the most common arrhythmia in clinical practise and its prevalence is increasing. Over the last 25 years, flecainide has been used extensively worldwide, and its capacity to reduce AF symptoms and provide long-term restoration of sinus rhythm (SR) has been well documented. The increased mortality seen in patients treated with flecainide in the Cardiac Arrhythmia Suppression Trial (CAST) study, published in 1991, still deters many clinicians from using flecainide, denying many new AF patients a valuable treatment option. There is now a body of evidence that clearly demonstrates that flecainide has a favourable safety profile in AF patients without significant left ventricular disease or coronary heart disease. As a result of this evidence, flecainide is now recommended as one of the first-line treatment options for restoring and maintaining SR in patients with AF under current treatment guidelines. The objective of this article is to review the literature pertaining to the pharmacological characteristics, safety and efficacy of flecainide, and to place this drug in the context of current therapeutic management strategies for AF.

Figures

Figure 1
Figure 1
Evidence-based treatment guideline recommendations for (A) newly discovered AF and (B) maintenance of sinus rhythm following cardioversion (adapted from Fuster et al.). *, Updated European Society of Cardiology recommendations; AF, atrial fibrillation; HF, heart failure; LVH, left ventricular hypertrophy.
Figure 2
Figure 2
Inhibition of Na+ channels by flecainide during rapid atrial activation attenuates excess cellular Ca2+ accumulation and reduces oxidative stress. ICa,L, L-type calcium current; ROS, reactive oxygen species; NFκB, nuclear factor-κB.
Figure 3
Figure 3
Proportion of subjects with successful pharmacological conversion (adapted from McNamara et al.). *, Control treatment includes groups receiving placebo, Verapamil, diltiazem, or digoxin; **, Vertical lines represent 95% confidence intervals for the proportion of subjects with successful pharmacological conversion; +, n equals the number of trials evaluating each comparison.

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