Safety of Flecainide in Treating Atrial Fibrillation

Atrial fibrillation (AF) is one type of arrhythmias, which as a, condition is caused by disturbances in the electrical impulses that govern the heart’s rhythm. Other types of arrhythmias include bradycardia, extrasystoles, ventricular tachycardia, wolf-parkinson-White syndrome, atrial flutter, torsades de pointes, supraventricular tachycardias, and ventricular fibrillation (Panchmatia, 2010).

Atrial fibrillation is the most common arrhythmia in the UK with 46000 cases diagnosed each year with the risk of dying doubles that of people with sinus rhythm of the heart (Panchmatia, 2010). It is a result of disorganised electrical activity in the atria leading to rapid and irregular heart rate. Flecainide is widely used and recommended by American and European heart societies as a first-line treatment for patients with symptomatic and no confirmation of structural heart disease. It is vital or critical that its safety whether in the short term or long term is addressed. This is in consideration that information on its safety in patients with atrial fibrillation is limited and based on American heart association and the European society of Cardiology guidelines.  Flecainide has a first line treatment in patients with atrial fibrillation alone or atrial fibrillation and hypertension without any evidence of structural heart disease (Almroth et al., 2011).

According to Almroth et al., (2001) in the CAST study, Anti-arrhythmic drugs are poorly tolerated, in addition to their poor efficacy, and at times serious side effects. The risk of proarrthynmia is also serious and as reported in the journal of internal medicine, a 2.5 fold increased risk of sudden cardiac arrest in patients treated with flecainidine or encainide compared to placebo (Almroth et al., 2011). This was done on people that had structural heart diseases during a median drug exposure of 10 months it was revealed that; patients with severely impaired left ventricular function were at a higher risk of 9.5% with Flecainide/encainide while, with placebo the risk of a sudden cardiac arrest was 3.6%(Almroth et al.,  2011).

Additionally in the study on flecainidine treatment, 18 patients discontinued treatment because of cardiac side effects with six of them classified as having proarrhythma or sudden cardiac death. Three patients had proarrhythmia; two patients experienced syncope during physical exercise associated with palpitations; five patients developed symptomatic structural heart disease during treatment,  and treatment was stopped in these patients as well as in another seven because of symptomatic sinus bradycardia (Almroth et al.,  2011). The main reason for this high figure was that six patients were included in a study in which a pacemaker algorithm for the prevention of atrial fibrillation was evaluated, and the remaining five patients developed symptomatic episodes of sinus arrest or syncope because of total atrioventricular block (Almroth et al., 2011).

According to Almroth et al, one randomized controlled trial has compared Flecainide with placebo and five have compared Flecainide with an alternative anti-arrhythmic treatment in atrial fibrillation populations. No deaths were reported in the 313 patients, in the six studies with a median Flecainide exposure time of 12 months(Almroth et al., 2011).

In accordance to Panchmatia’s article, major classes of anti-arrhythmic drugs; Flecainide, propranolol, beta blockers, Amiodarone and Verapamil, they all share a common outcome of benefits in the sense that they are all used to control symptoms in arrhythmia. In addition, although, they do not improve mortality they have been known to improve the quality of life (Panchmatia, 2010).

In another independent study, by Cardiol J  based on comparison of the safety and efficacy of  Flecainide versus propafenone in hospital outpatients, the probability of a patient staying on Flecainide after one year had a tendency to be higher than the probability of staying on propafenone(Cardiol, 1996). This was due to the greater proportion of secondary effects with propafenone (Cardiol, 1996).

Flecainide is one of the rhythm control drugs used for persistent AF in patients who have no structural heart disease (Panchmatia, 2010). Flecainide can cause nausea, vomiting and heart rhythm disorders as side effects; other classes of anti-arrhythmic drugs used in AF, for example,  Propranolol causes tiredness, impotence, low blood pressure, nightmares, and coldness of hands and feet(Panchmatia, 2010). The other class known as Amiodarone may interfere with night vision, lung problems, changes to liver function tests and deposits in the eye. Lastly, Verapamil may cause constipation, low blood pressure, ankle swelling and heart failure (Panchmatia, 2010). It is worthwhile to note that rate control is an acceptable alternative to rhythm control in a broad majority of patients (Panchmatia, 2010).

It should be noted that the final choice of rate or rhythm control needs consideration of a number of factors such as contraindications and side-effects of drugs, comorbidities, and individual patient choice with improving the quality of life (Panchmatia, 2010).

From what I have gathered the first step is to identify whether an Atrial fibrillation patient has a structural heart disease if so the first choice of treatment to administer is a beta blocker or amiodarone and in patients without structural heart disease, flacainidine or solatol can be tried. The side effects of most of these are far reaching, but they are known to improve lives. It is also worthwhile to note that other than Flecainide there is a wide range of drugs available to treat Atrial fibrillation, but they all serve the same purpose of controlling systems and even though they are not known for improving mortality they improve life’s quality(Panchmatia, 2010).

Flecainide has been associated with a fourfold increase in cardiovascular mortality compared with the general Swedish populations (Almroth et al., 2011). To minimise the risk of mortality, patients need to be tested first to make sure that the treatment path they take constitutes the least possible risks.

In conclusion, due to the increased incidence of sudden cardiac death and proarrhythmic events when Flecainide was used in the treatment of Atrial fibrillation and the side effects associated with it, a better alternative to this synthetic treatment method needs to be sought. Its side effects are far reaching, but the other available treatments are also coupled with serious side effects. Since it has been recommended by American and European heart societies as a first-line treatment for patients with symptomatic and no evidence of structural heart disease, Flecainide remains the best treatment. It leaves the population with not much of a choice.

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