From the Guidelines
Dronedarone (Multaq) is preferred over flecainide in patients with coronary artery disease (CAD) due to its better safety profile and lower risk of proarrhythmic effects. According to the ESC Guidelines 1, patients with coronary artery disease should not receive flecainide or propafenone, and instead, sotalol or dronedarone should be administered as first-line therapy. Dronedarone may be preferred based on its safety profile, as it has been demonstrated to be safe and well tolerated in a large study including patients with hypertension and possible LV hypertrophy 1.
The main concerns with flecainide in CAD patients are its potential to cause proarrhythmic effects and increase the risk of sudden cardiac death, especially in patients with previous myocardial infarction or other structural heart disease. In contrast, dronedarone, a Class III antiarrhythmic, does not have the same degree of negative inotropic effects or conduction slowing properties as flecainide. However, it's essential to note that dronedarone still carries risks, including potential liver toxicity and increased mortality in patients with severe heart failure or permanent atrial fibrillation.
Some key points to consider when using dronedarone in CAD patients include:
- Typical dose: 400 mg twice daily with meals
- Regular monitoring of liver function, ECG parameters, and cardiac status is essential
- Dronedarone is contraindicated in patients with NYHA class III–IV or recently decompensated heart failure
- Amiodarone should be considered when symptomatic AF recurrences continue to impact on the quality of life of these patients, as it is considered the drug of last resort in this population due to its extra-cardiac side effect profile 1.
From the Research
Comparison of Dronedarone and Flecainide in Patients with CAD
- Dronedarone is preferred over flecainide in patients with coronary artery disease (CAD) due to its better safety profile and efficacy in reducing cardiovascular outcomes 2.
- A study published in 2024 found that dronedarone was associated with better cardiovascular outcomes than other antiarrhythmic drugs, including flecainide, in patients with atrial fibrillation and CAD 2.
- Flecainide, a class IC antiarrhythmic drug, is contraindicated in patients with a history of myocardial infarction, but its effect on mortality and risk of proarrhythmia in patients with stable obstructive and nonobstructive epicardial CAD has not been fully assessed 3.
- Dronedarone, on the other hand, has been shown to be effective in reducing ventricular rate, preventing or delaying the recurrence of atrial fibrillation, and reducing cardiovascular morbidity and mortality in patients with AF or atrial flutter 4.
Safety Profile of Dronedarone and Flecainide
- Dronedarone has a more favorable safety profile compared to flecainide, with lower pulmonary and thyroid toxicity 4.
- Flecainide has been associated with an increased risk of proarrhythmia and mortality in patients with CAD, although a study published in 2021 found that flecainide use was not associated with an increase in all-cause mortality or ventricular arrhythmias in low-risk patients with stable nonobstructive CAD 3.
- Dronedarone is contraindicated in patients with unstable hemodynamic conditions, but it has been approved for clinical use by the Food and Drug Administration and the European Medicines Agency for the treatment of atrial fibrillation 4.
Clinical Guidelines and Recommendations
- The 2011 American College of Cardiology Foundation/American Heart Association/Heart Rhythm Society guidelines update recommends dronedarone for the management of AF patients with no or minimal heart disease, coronary artery disease, and hypertension with no left ventricular hypertrophy 5.
- Dronedarone is not recommended for patients with New York Heart Association (NYHA) class IV heart failure or NYHA class II-III heart failure with a recent decompensation requiring hospitalization or referral to a specialized heart failure clinic 5.