Flecainide Does Not Decrease Blood Pressure
Flecainide is not an antihypertensive agent and does not decrease blood pressure; rather, it can cause hypotension as an adverse effect, particularly in patients with structural heart disease or reduced left ventricular function. 1
Flecainide's Cardiovascular Effects
Flecainide is a class IC antiarrhythmic drug that primarily affects cardiac conduction through sodium channel blockade, not blood pressure regulation. 1
The drug has negative inotropic effects, meaning it can reduce cardiac contractility, which may lead to hypotension rather than controlled blood pressure reduction. 1
Hypotension is listed as a common adverse effect of flecainide, particularly when used in patients with compromised cardiac function. 1
Critical Contraindications in Hypertensive Patients
In hypertensive patients with left ventricular hypertrophy (LVH), flecainide should be avoided due to increased proarrhythmic risk. 1
Class IC agents such as flecainide are specifically not recommended in hypertensive patients with structural heart disease, severe LVH, or LV systolic dysfunction. 1
The European Heart Rhythm Association explicitly states that "antiarrhythmic drugs, e.g. class IC agents such as flecainide, are not recommended, especially where structural heart disease, such as severe LVH or LV systolic dysfunction, is evident." 1
Appropriate Use in Hypertensive Patients
Flecainide may be considered in hypertensive patients WITHOUT significant LVH (wall thickness <1.4 cm) and without structural heart disease for arrhythmia management. 1
In the absence of ischemia or LVH, both propafenone and flecainide are reasonable choices for atrial fibrillation rhythm control in hypertensive patients. 1
However, amiodarone becomes first-line therapy in the presence of substantial LVH, as it carries very low risk of ventricular proarrhythmia despite prolonging the QT interval. 1
Actual Antihypertensive Agents for Arrhythmia Patients
Beta-blockers, ACE inhibitors, and angiotensin receptor blockers (ARBs) are the appropriate agents that both control blood pressure AND reduce arrhythmia risk in hypertensive patients. 1
ACE inhibitors and ARBs provide agent-specific evidence of sudden cardiac death reduction that appears independent of blood pressure reduction. 1
Beta-blockers may be first-line treatment to maintain sinus rhythm in patients with hypertension, as they are more likely to maintain sinus rhythm after cardioversion compared to patients with lone atrial fibrillation. 1
Common Pitfall to Avoid
Do not prescribe flecainide with the expectation of blood pressure control—it is purely an antiarrhythmic agent. 1, 2
Always screen for structural heart disease, coronary artery disease, and significant LVH before initiating flecainide, as these are absolute contraindications. 3, 4
The hypotensive effect of flecainide is an adverse reaction, not a therapeutic benefit, and may be particularly problematic in elderly hypertensive patients already at risk for orthostatic hypotension. 1