Flecainide & Diltiazem???

I was wondering if those that are on Flecainide are also takiing somthing else to minimize risk of Flutter??? I've been on a low dose of Flecainide for 3 years now, it has kept me in NSR the whole time, no issues at all. I moved, so went to a new EP... this new guy wants me to add Diltiazem to the Flec, because of the risk of Flutter with the Flec. I REALLY don't want to add another drug, especially a beta-blocker... fatigue, amongst other issues. Seems like I haven't had any issues with just the Flec, is this still a risk?

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Sdweller
I was wondering if those that are on Flecainide are also takiing somthing else to minimize risk of Flutter??? I've been on a low dose of Flecainide for 3 years now, it has kept me in NSR the whole time, no issues at all. I moved, so went to a new EP... this new guy wants me to add Diltiazem to the Flec, because of the risk of Flutter with the Flec. I REALLY don't want to add another drug, especially a beta-blocker... fatigue, amongst other issues. Seems like I haven't had any issues with just the Flec, is this still a risk?

There is a small risk of one to one conduction between the atria and ventricles so, yes most EPs do consider this a risk and prescribe a beta blocker or Diltiazem with Flecainide. You could die if this did happen--it is not a risk of flutter, which is usually under 200 BPM, but more like getting 300 - 400 BPM ventricular rate.

I completely understand why you don't want to take a beta blocker and don't blame you one bit. For me, beta blockers are awful drugs that make me feel like I'm 95 years old. But the good news is diltiazem isn't a BB and doesn't have that effect on me. I take it daily for hypertension and it has no noticeable side effects for me. Hopefully, it will work well for you too because for the reasons Daisy mentioned, you really should be on a rate limiting drug of some type. Although the 1:1 conduction problem is rare, it can be fatal. A heart rate of 300+ isn't survivable.

Well thank you, this is very helpful from both of you.

I love diltiazem. Zero side effects and it calms my heart —better than Tenormin which I took for many decades and liked because it calmed me enough to sometimes convert. Technically I don’t need diltiazem anymore but I feel better on it. The drug, along with my pacemaker settings of burst therapy, increases my success rate of converting my annoying afib.

I have taken diltiazem as well and I agree with Carey- I felt like I couldn't walk across the room with a a BB. no issues with the diltiazem.

If you had a risk of flutter, you would know at this point. I have been on Flecainide for 40 + years. Have had two ablations, Still on Flecainide and I do not take BB or Diltiazem at this point. I do keep a supply of Diltiazem just in case. Take losartan low dose for BP. I do not know of anyone or heard of anyone who has been on Flecainide as long as me. I would ask, after being on the drug for years as you have, what is the risk.

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sldabrowski
If you had a risk of flutter, you would know at this point.

That's not true. Flecainide is known to become ineffective or even pro-arrhythmic for some people even after years of use. You're just lucky it's been effective for you for so long. I don't know what the risk is and I doubt anyone really has a handle on that since it's a very rare side effect.

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sldabrowski
If you had a risk of flutter, you would know at this point. I have been on Flecainide for 40 + years. Have had two ablations, Still on Flecainide and I do not take BB or Diltiazem at this point. I do keep a supply of Diltiazem just in case. Take losartan low dose for BP. I do not know of anyone or heard of anyone who has been on Flecainide as long as me. I would ask, after being on the drug for years as you have, what is the risk.

Curious how you use flec, PIP or daily? Also curious what your dose is and your weight?

I take it daily. 50x twice a day. WT is 160.

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sldabrowski
I take it daily. 50x twice a day. WT is 160.

Thanks! I asked as my hypothesis is that the flutter risk is proportional to dose and frequency of use. 50 mg BID is a low dose. I've used flec, mostly as PIP for 19 years. I've searched, but have not found any studies on this. Likewise, I've never taken a BB.

My initial PIP dose was 300 mg. I weighed 205# (93 kg). It worked well and I used it generally a couple of times a year, except for 2012 where I started consuming a lot of brie cheese. My AF frequency increased materially. I finally hypothesized that calcium in the brie was the culprit. I quit the brie and immediately dropped back to my prior AF frequency. In 2021, I had 15 episodes, a very large number for me. They were associated with 4 CV19 vaxxes. I started taking 50 mg flec/day for a few months, then dropped back to 25 mg/day. I tried to drop to zero unsuccessfully. I'd also noticed that I'd convert to what looked like flutter (NOT 1:1 - & looked like it as it was a very stable rhythm at a high rate) on a long duration beat to beat heart rate vs time trace (or a 30 second Kardia strip) and then have to get it to convert to afib (without any additional meds) before the afib would convert to NSR.

In 2022, for one episode I took flec that had expired in 2014. I always chew it for faster absorption. I could tell by the taste that it had oxidized somewhat. Interestingly, that episode converted in about 2 hours (common in the beginning) with no conversion to flutter. It dawned on me that as I'd changed my diet in 2009 and ultimately dropped weight down to 168# (76kg), that perhaps the dose was too high. My next episode, I took recently purchased flec but cut the dose to 200 mg. This worked similarly to the 300 mg of expired flec - short conversion & no flutter.

I then decided to not take any additional vax boosters, hypothesizing that the farther in time I got from taking a vax, the better my odds were of going back to no chronic flec. My last booster was in Oct 2022. I waited till June 2023 to stop the flec, initially cutting the dose to 12.5 mg/day for 15 days and then to 0 subsequently. I've had one (unprovoked) episode since, on Aug 1. I also think my PAC & PVC frequencies have dropped materially. My heart rate strap drys out over a little more than an hour, so haven't been able to get good overnight data. I've ordered some parts to modify the strap to use ECG electrodes and I'll try again once I get the parts. At the very least I've cut the number of episodes dramatically without taking flec chronically. The number of episodes in 2022 was 3, but I was taking 25 mg flec/day most days.

Thanks for info on Diltazem . I have been taking 100mg of flec twice a day plus metoprolol since 2008 — 15 years. Have had only a few short episodes per year until this year when I had one that required my first cardio version. Doing fine since, but suspect ablation could be in the cards? Weight 150…age 77…. very symptomatic.
Thanks you for this web site and the informative posts.