Pharmacology
Cardiovascular
Your consultant wishes to chemically cardiovert a patient who has presented to ED with new onset atrial fibrillation (AF). Which of the following would be an absolute contraindication to the use of flecainide:
Answer:
Sinus rhythm can be restored by electrical cardioversion, or pharmacological cardioversion with an oral or intravenous antiarrhythmic drug e.g. flecainide or amiodarone. Flecainide should not be given when there is known ischaemic or structural heart disease. Consider amiodarone in patients with left ventricular impairment or heart failure.Flecainide
Pharmacology / Cardiovascular
Last Updated: 17th April 2019
Indications
Flecainide acetate is an orally active class Ic antiarrhythmic and may be of value for serious symptomatic ventricular arrhythmias. It may also be indicated for junctional re-entry tachycardias and for paroxysmal atrial fibrillation. However, it has a negative inotropic action and can precipitate serious arrhythmias in a small minority of patients (including those with otherwise normal hearts).
Contraindications
Flecainide is contraindicated in:
- Abnormal left ventricular function
- Atrial conduction defects (unless pacing rescue available)
- Bundle branch block (unless pacing rescue available)
- Distal block (unless pacing rescue available)
- Haemodynamically significant valvular heart disease
- Heart failure
- History of myocardial infarction and either asymptomatic ventricular ectopics or asymptomatic non-sustained ventricular tachycardia
- Long-standing atrial fibrillation where conversion to sinus rhythm not attempted
- Second-degree or greater AV block (unless pacing rescue available)
- Sinus node dysfunction (unless pacing rescue available)
Cautions
Flecainide should be used with caution in:
- Atrial fibrillation following heart surgery
- Elderly (accumulation may occur)
- Patients with pacemakers (especially those who may be pacemaker dependent because stimulation threshold may rise appreciably)
Side Effects
Common side effects of flecainide include:
- Asthenia
- Dizziness
- Dyspnoea
- Fatigue
- Fever
- Oedema
- Pro-arrhythmic effects
- Visual disturbances
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
