Should flecainide be held after a procedure?

Should Flecainide Be Held After a Procedure?

Yes, flecainide should generally be avoided or held after cardiac surgery procedures, as it is not recommended for post-cardiac surgery atrial fibrillation due to significantly increased mortality risk in patients with coronary artery disease and ventricular ectopy. 1

Critical Safety Concern for Post-Cardiac Surgery Use

• Flecainide is specifically contraindicated for treatment of atrial fibrillation following cardiac surgery because it has been associated with significantly increased mortality in patients with coronary artery disease and ventricular ectopy 1

• The American College of Chest Physicians explicitly states that "this class of medication is not recommended for the treatment of post-cardiac surgery AF" despite the agents being reasonably efficacious in other settings 1

Context-Specific Guidance

For Cardiac Surgery Patients:

• Hold flecainide and do not restart it in the immediate post-cardiac surgery period 1
• Consider alternative agents such as amiodarone, which is relatively safe in patients with structural heart disease and does not cause hypotension 1
• Beta-blockers are recommended as first-line therapy for post-cardiac surgery arrhythmias 2

For Non-Cardiac Thoracic Surgery:

• Flecainide may actually be beneficial in preventing arrhythmias after non-cardiac thoracic operations, with studies showing it more effective than digoxin (7% vs 47% failure rate) 3
• Prophylactic flecainide administration (0.15 mg/kg/h infusion after 2 mg/kg loading dose) effectively reduced cardiac arrhythmias after thoracic operations without side effects 4

For Ablation Procedures:

• Flecainide is typically continued after atrial fibrillation ablation procedures 5
• If symptomatic bradycardia develops post-ablation, reduce or discontinue the beta-blocker first while maintaining flecainide 5
• If bradycardia persists, consider reducing flecainide dose from 150mg BID to 100mg BID rather than complete discontinuation 5

Important Caveats

• The mortality risk associated with flecainide stems from the CAST trial data in patients with structural heart disease and coronary artery disease 6, 7
• Flecainide remains safe and effective in appropriately selected patients without structural heart disease or coronary artery disease 6, 7, 8
• Current guidelines recommend flecainide as first-line therapy for atrial fibrillation in patients without structural heart disease 1, 6, 7

Monitoring Requirements

• If flecainide must be continued or restarted post-procedure, obtain ECG at least once in the first 2 weeks following medication changes 2
• Maintain potassium levels ≥4.0 mEq/L and replenish magnesium before initiating antiarrhythmic therapy 2, 5
• Monitor for QT prolongation, bradycardia, and conduction abnormalities 2, 7