Should Flecainide (antiarrhythmic medication) be continued perioperatively (periooperative period) in patients undergoing surgery?

Perioperative Management of Flecainide

Continue flecainide perioperatively in patients undergoing noncardiac surgery, as there is no guideline recommendation to discontinue antiarrhythmic medications used for symptomatic arrhythmias, and abrupt discontinuation may precipitate life-threatening arrhythmias.

Rationale for Continuation

• The 2007 ACC/AHA perioperative guidelines explicitly state that beta blockers should be continued in patients receiving them for symptomatic arrhythmias 1. While this recommendation specifically addresses beta blockers, the same principle applies to antiarrhythmic agents like flecainide that are treating active arrhythmic conditions.

• Flecainide is a Class IC antiarrhythmic used for atrial fibrillation and supraventricular tachycardia in patients without structural heart disease 2. Discontinuing it perioperatively risks breakthrough arrhythmias during the physiologically stressful surgical period.

• The 2006 ACC/AHA/ESC atrial fibrillation guidelines recommend that antiarrhythmic therapy should not be discontinued in patients requiring rhythm control 1. The perioperative period does not change this fundamental management principle.

Critical Safety Considerations

Absolute Contraindications to Flecainide Use

Do not use flecainide in patients with:

• Coronary artery disease or structural heart disease 3, 2, 4
• Left ventricular dysfunction or heart failure 3, 4
• History of myocardial infarction 4

Perioperative Monitoring Requirements

• Monitor for proarrhythmic effects, particularly rapid atrial flutter with 1:1 AV conduction, which can cause hemodynamic compromise 2. This is especially concerning in the perioperative setting where sympathetic stimulation may facilitate rapid ventricular rates.

• Check electrolytes preoperatively and maintain potassium ≥4.0 mEq/L 3. Hypokalemia or hyperkalemia alter the effects of Class I antiarrhythmics and increase proarrhythmic risk.

• Assess for conduction abnormalities on preoperative ECG 3. Flecainide causes dose-related increases in PR interval (average 25%), QRS duration (average 25%), and can cause new bundle branch block in 4% of patients.

Specific Perioperative Risks

Flecainide may cause:

• Sinus node dysfunction including sinus pause, sinus arrest, and symptomatic bradycardia (1.2%) 3
• Second-degree AV block (0.5%) or third-degree AV block (0.4%) 3
• Negative inotropic effects that can precipitate heart failure, particularly in patients with reduced myocardial function 3

Practical Management Algorithm

Preoperative Assessment

1. Verify the indication for flecainide - Confirm it is being used for atrial fibrillation or SVT in a patient without structural heart disease 2, 4

2. Obtain baseline ECG - Document PR interval, QRS duration, and QT interval 3

3. Check renal function - Flecainide requires dose adjustment in renal dysfunction 4

4. Verify electrolytes are normal - Correct any abnormalities before surgery 3

Intraoperative Management

• Continue the patient's usual oral dose on the morning of surgery with a sip of water (based on the principle that symptomatic arrhythmia medications should be continued) 1

• Have AV nodal blocking agents immediately available (beta blockers or calcium channel blockers) in case rapid atrial flutter develops 2

• Maintain continuous ECG monitoring throughout the perioperative period 3

Postoperative Management

• Resume oral flecainide as soon as the patient can tolerate oral medications 1

• Monitor for 72 hours postoperatively, as this is the peak period for postoperative arrhythmias after thoracic surgery 5, 6

Common Pitfalls and How to Avoid Them

Pitfall #1: Discontinuing flecainide "to be safe"

• This increases the risk of breakthrough atrial fibrillation or SVT during the stress of surgery 1, 2
• The perioperative guidelines do not recommend stopping antiarrhythmics for symptomatic arrhythmias 1

Pitfall #2: Using flecainide in patients with unrecognized structural heart disease

• Always verify absence of coronary disease, heart failure, or prior MI before continuing flecainide 3, 4
• If structural heart disease is present, consider switching to amiodarone preoperatively 1

Pitfall #3: Failing to recognize rapid atrial flutter with 1:1 conduction

• Flecainide can convert atrial fibrillation to atrial flutter, and perioperative sympathetic stimulation may allow 1:1 AV conduction 2
• Always have AV nodal blocking agents immediately available 2

Pitfall #4: Ignoring drug interactions

• Flecainide levels increase with concurrent use of amiodarone, cimetidine, and some beta blockers 4
• Anesthetic agents with negative inotropic effects may have additive cardiac depression with flecainide 3

Pitfall #5: Not adjusting for renal dysfunction

• Flecainide is renally cleared and requires dose reduction in renal impairment 4
• Perioperative acute kidney injury can precipitate flecainide toxicity 4

Evidence Supporting Perioperative Continuation

Research in thoracic surgery demonstrates flecainide's safety and efficacy:

• Flecainide reduced postoperative arrhythmias after noncardiac thoracic surgery from 38% (placebo) to 0% (flecainide) without adverse effects 6
• Flecainide was more effective than digoxin in preventing arrhythmias after thoracic operations (7% failure rate vs 47%) 5

These studies used intravenous flecainide at therapeutic serum levels (200-600 ng/mL) without significant side effects 5, 6, supporting the safety of continuing oral flecainide perioperatively in appropriately selected patients.