Safety and efficacy of flecainide for patients with catecholaminergic polymorphic ventricular tachycardia: A systematic review and meta-analysis.

Background: Owing to reports of recurrent cardiac events in some catecholaminergic polymorphic ventricular tachycardia (CPVT) patients using beta-blockers, safer alternatives are being investigated. Flecainide is an alternative adjunctive anti-arrhythmic agent known to provide incomplete protection to CPVT patients. Methods: To investigate the efficacy and tolerability of flecainide, we searched 4 databases for retrospective cohort studies (RCs) and randomized controlled trials (RCTs) investigating the efficacy and safety of flecainide for CPVT patients. Data were extracted and analyzed (risk ratio [RR] or mean difference [MD]) using RevMan software. Seven RCs and 1 RCT (333 CPVT patients; 152 patients treated with flecainide) were identified. Results: Flecainide monotherapy was superior to standard therapy in alleviating the risk of arrhythmic events (RR=0.46, confidence interval [CI]=[0.38, 0.56], P<.00001) and exercise-induced arrhythmia scores (MD=-0.39, CI=[-0.74, -0.05], P=.03). Combination therapy of flecainide and b-blockers was superior to b-blocker monotherapy in reducing the risk of arrhythmic and symptomatic events (RR=0.29, CI=[0.13, 0.69], P=.005; RR=0.36, CI=[0.20, 0.62], P=.0003, respectively), peak heart rate (MD= -16.81, CI=[-28.21, -5.41], P=.004), and exercise-induced arrhythmia scores (MD= -1.87, CI=[-2.71, 1.04], P<.0001). Flecainide did not increase the risk of all side effects (RR=0.76, CI=[0.42, 1.40], P=.38) compared to that with b-blockers alone. No deaths were reported among patients treated with flecainide. Conclusions: Flecainide is an effective and safe anti-arrhythmic agent, and its use as a monotherapy might be a good alternative for CPVT patients with b-blocker intolerance. Combination therapy was superior to b-blocker monotherapy. More randomized clinical trials are required to explore the long-term efficacy and safety of flecainide in these patients.