Department of Medicine, School of Medicine, University of Utah, Salt Lake City, UT.
Intermountain Medical Center, Intermountain Heart Institute, Murray, UT.
Am Heart J. 2022 Jan;243:127-139. doi: 10.1016/j.ahj.2021.08.013. Epub 2021 Sep 17.
Class 1C antiarrhythmic drugs (AAD) have been associated with harm in patients treated for ventricular arrhythmias with a prior myocardial infarction. Consensus guidelines have advocated that these drugs not be used in patients with stable coronary artery disease (CAD). However, long-term data are lacking to know if unique risks exist when these drugs are used for atrial fibrillation (AF) in patients with CAD without a prior myocardial infarction.
In 24,315 patients treated with the initiation of AADs, two populations were evaluated: (1) propensity-matched AF patients with CAD were created based upon AAD class (flecainide, n = 1,114, vs class-3 AAD, n = 1,114) and (2) AF patients who had undergone a percutaneous coronary intervention or coronary artery bypass graft (flecainide, n = 150, and class-3 AAD, n = 1,453). Outcomes at 3 years for mortality, heart failure (HF) hospitalization, ventricular tachycardia (VT), and MACE were compared between the groups.
At 3 years, mortality (9.1% vs 19.3%, P < .0001), HF hospitalization (12.5% vs 18.3%, P < .0001), MACE (22.9% vs 36.6%, P < .0001), and VT (5.8% vs 8.5%, P = .02) rates were significantly lower in the flecainide group for population 1. In population 2, adverse event rates were also lower, although not significantly, in the flecainide compared to the class-3 AAD group for mortality (20.9% vs 25.8%, P = .26), HF hospitalization (24.5% vs 26.1%, P = .73), VT (10.9% vs 14.7%, P = .28) and MACE (44.5% vs 49.5%, P = .32).
Flecainide in select patients with stable CAD for AF has a favorable safety profile compared to class-3 AADs. These data suggest the need for prospective trials of flecainide in AF patients with CAD to determine if the current guideline-recommended exclusion is warranted.
1C 类抗心律失常药物（AAD）在心肌梗死后接受室性心律失常治疗的患者中与危害相关。共识指南主张，在稳定型冠状动脉疾病（CAD）患者中，不应使用这些药物。然而，缺乏长期数据来了解当这些药物在没有先前心肌梗死的 CAD 患者中用于心房颤动（AF）时是否存在独特的风险。
在 24315 名接受 AAD 起始治疗的患者中，评估了两个人群：（1）基于 AAD 类别（氟卡尼，n=1114，与 3 类 AAD，n=1114）创建了经倾向评分匹配的 CAD 合并 AF 患者；（2）接受经皮冠状动脉介入治疗或冠状动脉旁路移植术的 AF 患者（氟卡尼，n=150，3 类 AAD，n=1453）。比较两组患者 3 年时的死亡率、心力衰竭（HF）住院率、室性心动过速（VT）和主要不良心血管事件（MACE）。
3 年时，死亡率（9.1% vs 19.3%，P<0.0001）、HF 住院率（12.5% vs 18.3%，P<0.0001）、MACE（22.9% vs 36.6%，P<0.0001）和 VT（5.8% vs 8.5%，P=0.02）发生率在氟卡尼组人群 1 中显著较低。在人群 2 中，与 3 类 AAD 相比，氟卡尼组的不良事件发生率也较低，尽管无统计学意义，死亡率（20.9% vs 25.8%，P=0.26）、HF 住院率（24.5% vs 26.1%，P=0.73）、VT（10.9% vs 14.7%，P=0.28）和 MACE（44.5% vs 49.5%，P=0.32）。
氟卡尼在患有稳定型 CAD 的 AF 患者中的选择人群中具有比 3 类 AAD 更好的安全性。这些数据表明需要进行前瞻性氟卡尼治疗 AF 合并 CAD 患者的临床试验，以确定当前指南推荐的排除是否合理。
