From the Guidelines
Flecainide is not recommended for patients with heart failure with preserved ejection fraction (HFpEF) due to the potential risk of worsening heart failure and proarrhythmic effects, as suggested by the 2024 ESC guidelines for the management of atrial fibrillation 1. When considering rhythm control for atrial fibrillation in patients with HFpEF, other antiarrhythmic options like dronedarone are preferred, as they have been recommended for patients with HFpEF in the 2024 ESC guidelines 1. Key points to consider when managing HFpEF include:
- Controlling blood pressure and managing underlying conditions
- Using diuretics for symptom relief
- Considering newer options like SGLT2 inhibitors
- Avoiding routine use of nitrates or phosphodiesterase-5 inhibitors, as they have not shown benefit in improving activity levels, quality of life, exercise tolerance, or NT-proBNP levels in patients with HFpEF, as noted in the 2017 ACC/AHA/HFSA focused update 1. If flecainide must be used in a HFpEF patient, it should be initiated at a low dose with careful monitoring and gradual titration, due to its potential proarrhythmic effects and risk of worsening heart failure. The use of flecainide or propafenone is recommended in patients with AF requiring long-term rhythm control, excluding those with impaired left ventricular systolic function, severe left ventricular hypertrophy, or coronary artery disease, as stated in the 2024 ESC guidelines 1. Concomitant use of a beta-blocker, diltiazem, or verapamil should be considered in AF patients treated with flecainide or propafenone, to prevent 1:1 conduction if their rhythm is transformed to atrial flutter, as recommended in the 2024 ESC guidelines 1.
From the FDA Drug Label
HEART FAILURE Flecainide acetate has a negative inotropic effect and may cause or worsen CHF, particularly in patients with cardiomyopathy, preexisting severe heart failure (NYHA functional class III or IV) or low ejection fractions (less than 30%). In patients with supraventricular arrhythmias new or worsened CHF developed in 0. 4% (1/225) of patients. In patients with sustained ventricular tachycardia during a mean duration of 7.9 months of flecainide acetate therapy, 6.3% (20/317) developed new CHF. In patients with sustained ventricular tachycardia and a history of CHF, during a mean duration of 5.4 months of flecainide acetate therapy, 25. 7% (78/304) developed worsened CHF.
Flecainide and HFpEF: Flecainide may cause or worsen heart failure, including in patients with heart failure with preserved ejection fraction (HFpEF), due to its negative inotropic effect. The drug label does not provide specific information on the use of flecainide in patients with HFpEF. However, it recommends cautious use in patients with a history of heart failure or myocardial dysfunction, and careful monitoring of cardiac function.
- Key considerations:
- Flecainide may worsen heart failure in patients with preexisting severe heart failure or low ejection fractions.
- The initial dosage in patients with a history of heart failure or myocardial dysfunction should be no more than 100 mg bid.
- Patients should be monitored carefully for signs of worsening heart failure. 2
From the Research
Flecainide and HFpEF
- There is no direct evidence on the use of flecainide in patients with heart failure with preserved ejection fraction (HFpEF) in the provided studies.
- However, the studies discuss the use of other medications, such as beta-blockers and calcium channel blockers, in patients with HFpEF 3, 4, 5, 6, 7.
- Beta-blockers have been shown to be effective in reducing all-cause mortality and hospitalization in patients with HFpEF, with a significant reduction in risk ratio (RR = 0.60; 95% CI = 0.43-0.83; p = .002) for all-cause mortality and (RR = 0.54; 95% CI = 0.37-0.80; p = .002) for hospitalization 7.
- Calcium channel blockers have also been shown to be effective, but to a lesser extent, with a risk ratio of all-cause mortality (RR = 0.77; 95% CI = 0.60-0.98; p = .03) and hospitalization (RR = 0.63; 95% CI = 0.44-0.90; p < .00001) 7.
Management of HFpEF
- The management of HFpEF is focused on symptom management and treatment of comorbidities, as there are no approved treatments specifically indicated for HFpEF 4, 6.
- Primary care providers play a critical role in the delivery of holistic, patient-centric care from diagnosis to management and palliative care 6.
- Comprehensive management of HFpEF includes exercise, treatment of risk factors, and comorbidities, as well as classification based on phenotypes to facilitate a more targeted approach to treatment 4.