Flecainde and hospital observation?

Hello,
There seems to be a lot of references to Flecainide being started in a hospital while under observation yet it seems as though this protocol is mostly not being followed, including with my own cardiologist. Has anyone started this medication under observation? Any thoughts on why this protocol isn’t being followed and the risks of taking this medication while not being in the hospital? I have no structural issues and a perfectly clean stress echo. They also want to bump me up to 100mg week two after an EKG but I’m pushing to stay on 50mg unless I continue to be symptomatic. After week 2 they’re calling for an EKG and stress echo. (I’m assuming this is standard protocol).



Edited 1 time(s). Last edit at 05/24/2019 02:56PM by bkimura.

In the last 10 years I can only recall hearing from one person who was started in the hospital, and they had a bunch of other issues complicating things. It's just not often done anymore. The instructions to begin it under observation were written by the FDA years and years ago when flecainide was a new drug. With more experience, they've learned that it's just not necessary for most patients.

The second EKG and stress echo aren't part of any protocol I'm aware of, and I can't imagine why they're doing a second stress echo so soon unless perhaps they found something suspicious on the first one.

When I started Flec, 300 mg as pill in pocket, I started in the hospital at my EP's request. I have never had any issues other than AFIB shown in any of my previous heart test. I have no structural heart problems. It wasn't a big deal. I just went into the local emergency, was given 300mg flec, and went home a couple hours later.

Once on the flec, I always did a minimum dose with more added if the first dose (usually100 mg) didn't do the trick. No more than 300mg in a 24 hour period is what I remember. I had a couple ablations 4 years ago with good success. I still have some current flec sitting around just in case.

The flec worked for me for a few years , then not so much.



Good luck with it....ron

Thanks Carey. My original stress echo was 100% clean. I was told this multiple times. I got the impression that the 2nd stress echo was standard protocol. The plan was communicated as follows:

50mg Flecainide for 1-week
Come in for an EKG
100mg for week-2
Come in for stress echo

From the American College of Cardiology

“When starting a patient on flecainide, it is prudent to do a treadmill stress test after the patient is fully loaded.”

I suspect this is why they want me to return for a stress test after week 2 and ramping up to 100mg. (I think it’s to check the QRS duration)
I may be mistaken on the echo but they definitely mentioned a stress test.

Quote
bkimura
From the American College of Cardiology

“When starting a patient on flecainide, it is prudent to do a treadmill stress test after the patient is fully loaded.”

I suspect this is why they want me to return for a stress test after week 2 and ramping up to 100mg. (I think it’s to check the QRS duration)
I may be mistaken on the echo but they definitely mentioned a stress test.

Okay, so I was wrong that it's not protocol, but that's not a protocol followed much these days. Your docs are just being super careful, which is a good thing.

Propafenone and Flecainide, the “first line” anti-arrhythmics, are often started outside of a hospital setting. They don’t prolong the QT interval, which is the main reason to put a patient under 48 or 72 hour observation. A prolonged QT interval carries a risk for ventricular arrhythmia, which is bad. Now, if a patient has significant co-morbidities or the starting dose is a maximum one, then the prescribing physician may elect for a hospital setting.

I was started on Flec following my first ablation. I was in the hospital at the time but only because they were trying to get my INR right.



Edited 1 time(s). Last edit at 05/25/2019 04:40AM by rocketritch.

Quote
wolfpack
Propafenone and Flecainide, the “first line” anti-arrhythmics, are often started outside of a hospital setting. They don’t prolong the QT interval, which is the main reason to put a patient under 48 or 72 hour observation. A prolonged QT interval carries a risk for ventricular arrhythmia, which is bad. Now, if a patient has significant co-morbidities or the starting dose is a maximum one, then the prescribing physician may elect for a hospital setting.

3.5 years ago, when I had my 2nd afib episode (ER diagnostic), they cardioverted me electrically, then sent me home under propafenone, without further observation. As it didn't work, the EP called me back for a stress test some days later and the ECG revealed enlarged QRS (a phenomenon happening when my HR goes above 120 bpm). It's a well known possible adverse effect of propafenone and flecainide.
I then took sotalol, had ablations, took flecainide (max 100mg/day because of the above)...

Quote
Carey
Okay, so I was wrong that it's not protocol, but that's not a protocol followed much these days. Your docs are just being super careful, which is a good thing.

From my own experience, It seems it's the same here in Belgium : not a strictly followed protocol.

I’m not sure if we’re talking about the same thing, but the QT interval is the time between ventricular depolarization (QRS complex) and repolarization (T wave). If that’s too long then you can get a reentrant rhythm in the ventricles. QT interval also needs to shorten with increasing HR, thus it is often quoted as QTc (QT corrected). There are a number of formulas for doing this, each having its own merits.

Dofetilide (Tikosyn) carries a much higher risk of QT prolongation than do Propafenone or flecainide. But it’s still only something like 1% of the patient population.

In my case, the QT interval is in the normal range, but the QRS tends to exceed 0,1sec. There's something potentially dangerous somewhere, but I'm no cardiologist, so I don't know. There's likely another segment inside the QT interval that shortens to compensate for the prolonged QRS, but it's too subtle for me, as my competence in ECG reading is limited, especially when the recording comes from a stress test (HR just above 120bpm and artifacts in the tracing).

A QRS wider than 0.12 seconds is considered abnormal. It can be caused by several things but bundle branch block is the most common.

My cardiologist said it's a conduction problem happening when I'm taking flec. BBB has never been mentioned.

Yeah, there are other causes. Just saying BBB is the most common.