Is flecainide or sotalol a better choice for atrial fibrillation?
Anti-arrhythmics are not my favorite. I first went back to the 2014 AHA/ACC guidelines, attached, which share that both these drugs are viable options. Flecainide should be avoided in patients with a history of ischemic heart disease, systolic dysfunction, and/or conduction disease. Sotalol should be avoided in patients with renal dysfunction and/or a prolonged QT interval. That said, the guidelines don't make a strong recommendation about which anti-arrhythmic is best:
Table 13. Dosage and Safety Considerations for Maintenance of Sinus Rhythm in AF
Then I searched pubmed for direct comparisons in the outpatient setting. No, but I did find this nice observational study from Northwestern which found that general cardiologists prescribe AAs 11% of the time as compared to EPs's 32% - sounds about right. For our specific question, this study cited EP rxs for sotalol at 20% and flecainide at 13% (for gen cards, sotalol was 20%, no flecainide). I also like this admittedly older expert summary from ACC - it's definitely worth the read, and I appreciate what he says about assessing for clinical improvement.
This clinical question has limited data, so we'll have to use expert opinion to fill the gap. Your Core Conference EP lectures are coming up which is a great opportunity to dive deeper. For me, I'm going to try to use sotalol more in clinic going forward (yay practice-based learning and improvement). As always, I welcome your thoughts.
January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Circulation. 2014;130(23). doi:https://doi.org/10.1161/cir.0000000000000041
Reiffel JA. Ten Pearls for the Use of Antiarrhythmic Drugs for Atrial Fibrillation - American College of Cardiology. American College of Cardiology. Published 2014. https://www.acc.org/latest-in-cardiology/articles/2014/07/18/15/12/ten-pearls-for-the-use-of-antiarrhythmic-drugs-for-atrial-fibrillation
Teme T, Goldberger JJ. Atrial fibrillation practice patterns among cardiac electrophysiologists and cardiologists. Cardiology Journal. 2014;21(3):293-298. doi:https://doi.org/10.5603/cj.a2013.0089
