A pilot study on the acute conversion and maintenance of sinus rhythm in rheumatic atrial fibrillation using oral flecainide

Abstract

Background Achievement of sinus rhythm (SR) is an important goal in rheumatic atrial fibrillation (AF). Studies in rheumatic AF have often used amiodarone for rhythm control. Flecainide has not been studied in these patients due to concerns of underlying structural heart disease. Methods Pharmacological cardioversion by oral single loading dose (SLD) of Flecainide (4 mg/kg, ≤300 mg) was tested in 50 patients with rheumatic AF (MVA 1.51 ± 0.19 mm 2 , age 46.2 ± 10.28 yrs, AF duration 3.10 ± 1.7 yrs, LA size: 44.42 ± 7.48 mm). Non-converters underwent DC cardioversion (DCC) at 24 h. All patients received oral flecainide and ββ/diltiazem at discharge. Results At 24 h, 38/50 (76%) achieved SR (2 with SLD; 36 after DCC). At 30 days (mean Flecainide dose 116.5 ± 10.5 mg) successful maintenance of SR was noted in 31/38 (89%). At 1 year, 30/38 (79%) of the initial converters and 60% of the overall population maintained SR. Those in SR had significantly better NYHA Class (1.1 ± 0.12 vs 1.3 ± 0.10, p = 0.03) and mean PCS8 score (50.11 ± 5.337 vs 46.84 ± 5.379, p = 0.02). AF duration (OR 0.594 CI 0.375–0.940, p = 0.02) and LA size (OR 0.840, CI 0.757–0.933, p = 0.001) were found to be the only significant predictors of successful outcomes. Patients with AF duration <3.5 years and LA size <51 mm had 85% and 75% chance of maintaining SR at 1 year, respectively. Conclusion Flecainide is safe and effective for achieving and maintaining SR in patients of rheumatic AF who are unlikely to have underlying coronary artery disease or ventricular dysfunction.

Management of atrial fibrillation in rheumatic heart disease

“…In a pilot study of 50 rheumatic AF patients, a single oral dose of 4 mg/kg of flecanide effectively cardioverted 4% to sinus rhythm, and 72% achieved sinus rhythm with direct current cardioversion (DCCV). 42 In a study of 165 patients with rheumatic AF, ibutilide successfully restored sinus rhythm in 77%, with a mean conversion time of 7.9 ± 4.1 minutes. Torsades de pointes requiring defibrillation developed in 1.8% of patients at a mean interval of 55 ± 37 minutes, and there were no deaths.…”

“…DCCV is effective and safe in restoring sinus rhythm in most rheumatic AF patients, especially after valvular interventions such as balloon valvotomy. 42 To improve cardioversion success and prevent relapses, DCCV should be done after at least 1 month of oral amiodarone loading. 45 …”

“…In a pilot study of 50 patients, oral flecainide successfully maintained sinus rhythm in 60% of patients at 1-year follow-up. 42 Further larger randomized studies of flecanide are necessary to confirm its efficacy. Rheumatic AF patients tend to be young, with fewer comorbidities, have a normal left ventricular function, and need long-term antiarrhythmic therapy to maintain sinus rhythm.…”

Outcomes and care quality metrics for people living with rheumatic heart disease and atrial fibrillation in Uganda

“… 12 Other studies have elucidated potential AF rate and rhythm management strategies specific to those with RHD. 13 , 14 , 15 , 16 , 17 , 18 , 19 Nonetheless, there remains a paucity of data to guide management of AF in patients with RHD within their respective local contexts. National and regional health metrics are essential in guiding implementation strategies and policy interventions to improve health outcomes.…”

Flecainide for conversion and maintenance of sinus rhythm after mitral valve replacement in rheumatic atrial fibrillation

“…We have previously reported that oral flecainide was effective in maintaining SR in patients with rheumatic AF, following previous balloon mitral valvotomy (BMV). 16 In this prospective single center stud, we assessed the safety and efficacy of oral flecainide in rheumatic AF following mitral valve replacement.…”