Evaluation of flecainide acetate in the management of patients at high risk of sudden cardiac death

The clinical effectiveness of flecainide acetate was evaluated in 36 patients (29 male and 7 female, average age 56 years) in whom therapy with previous antiarrhythmic agents had failed. All patients had documented ventricular tachycardia on Holter electrocardiographic recording and 31 of 36 (86%) had had syncope or required cardiopulmonary resuscitation, or both. Angiographic findings demonstrated significant coronary artery disease in 22 (61%) and primary left ventricular dysfunction in 14 (39%), with a left ventricular ejection of 0.39 ± 0.4. Patients were treated with an average flecainide dose of 302 ± 76 mg/day. The follow-up time was 101 ± 156 days. Thirty-two of 36 patients (89%) had complete elimination of ventricular tachycardia from Holter monitoring and only 2 patients had flecainide discontinued because of noncardiac side effects (numbness, blurred vision and ataxia). However, the drug was subsequently discontinued in 5 patients because of cardiac side effects (proarrhythmic effect in 2, sinus bradycardia in 1, complete atrioventricular block in 1 and new left bundle branch block in 1) and 10 patients died during flecainide therapy (1 with cerebral stroke, 3 with congestive heart failure and 6 with incessant ventricular tachycardia). A comparison of the general cardiac features of those who died with those who did not revealed a significantly lower ejection fraction (0.24 ± 0.1 vs 0.45 ± 0.1, p < 0.05) and a significantly higher flecainide dose (350 ± 85 versus 276 ± 59 mg/day, p < 0.05). These results demonstrate that flecainide can suppress ventricular tachycardia in patients at high risk of life-threatening ventricular tachyarrhythmias. However, it should be used with caution in patients with severely depressed left ventricular function.