BACKGROUND: In severely affected patients with catecholaminergic polymorphic ventricular tachycardia, beta-blockers are often insufficiently protective. The purpose of this study was to evaluate whether flecainide is associated with a lower incidence of arrhythmic events (AEs) when added to beta-blockers in a large cohort of patients with catecholaminergic polymorphic ventricular tachycardia. METHODS: From 2 international registries, this multicenter case cross-over study included patients with a clinical or genetic diagnosis of catecholaminergic polymorphic ventricular tachycardia in whom flecainide was added to beta-blocker therapy. The study period was defined as the period in which background therapy (ie, beta-blocker type [beta1-selective or nonselective]), left cardiac sympathetic denervation, and implantable cardioverter defibrillator treatment status, remained unchanged within individual patients and was divided into pre-flecainide and on-flecainide periods. The primary end point was AEs, defined as sudden cardiac death, sudden cardiac arrest, appropriate implantable cardioverter defibrillator shock, and arrhythmic syncope. The association of flecainide with AE rates was assessed using a generalized linear mixed model assuming negative binomial distribution and random effects for patients. RESULTS: A total of 247 patients (123 [50%] females; median age at start of flecainide, 18 years [interquartile range, 14-29]; median flecainide dose, 2.2 mg/kg per day [interquartile range, 1.7-3.1]) were included. At baseline, all patients used a beta-blocker, 70 (28%) had an implantable cardioverter defibrillator, and 21 (9%) had a left cardiac sympathetic denervation. During a median pre-flecainide follow-up of 2.1 years (interquartile range, 0.4-7.2), 41 patients (17%) experienced 58 AEs (annual event rate, 5.6%). During a median on-flecainide follow-up of 2.9 years (interquartile range, 1.0-6.0), 23 patients (9%) experienced 38 AEs (annual event rate, 4.0%). There were significantly fewer AEs after initiation of flecainide (incidence rate ratio, 0.55 [95% CI, 0.38-0.83]; P=0.007). Among patients who were symptomatic before diagnosis or during the pre-flecainide period (n=167), flecainide was associated with significantly fewer AEs (incidence rate ratio, 0.49 [95% CI, 0.31-0.77]; P=0.002). Among patients with ≥1 AE on beta-blocker therapy (n=41), adding flecainide was also associated with significantly fewer AEs (incidence rate ratio, 0.25 [95% CI, 0.14-0.45]; P<0.001). CONCLUSIONS: For patients with catecholaminergic polymorphic ventricular tachycardia, adding flecainide to beta-blocker therapy was associated with a lower incidence of AEs in the overall cohort, in symptomatic patients, and particularly in patients with breakthrough AEs while on beta-blocker therapy.

Agnes Ginges Centre for Molecular Cardiology at Centenary Institute University of Sydney Australia

Amsterdam Cardiovascular Sciences Heart Failure and Arrhythmias The Netherlands

Cardiac Inherited Disease Group New Zealand Green Lane Paediatric and Congenital Cardiac Services Starship Children's Hospital Auckland

Cardiovascular Genetics Center Institut d'Investigació Biomèdica Girona Hospital Trueta CIBERCV University of Girona Spain

Center for Biomedical Network Research on Cardiovascular Diseases Madrid Spain

Children's Heart Centre 2nd Faculty of Medicine Charles University Prague and Motol University Hospital Czech Republic

Department of Cardiology Erasmus MC University Medical Center Rotterdam The Netherlands

Department of Cardiology Hospital Universitario y Politécnico La Fe Valencia Spain

Department of Cardiology Rigshospitalet Copenhagen Denmark

Department of Cardiology Royal Brompton Hospital London United Kingdom

Department of Cardiology University of Groningen University Medical Centre Groningen The Netherlands

Department of Cardiovascular Diseases University Hospitals Leuven Belgium

Department of Cardiovascular Medicine Shiga University of Medical Science Otsu Japan

Department of Medicine University Medical Center Mannheim Germany

Department of Paediatric Cardiology Vall d'Hebron University Hospital Barcelona Spain

Department of Paediatrics Hong Kong Children's Hospital China

Department of Pediatric Cardiology and Cardiac Surgery Bambino Gesù Children's Hospital and Research Institute Rome Italy

Department of Pediatric Cardiology and Intensive Care Medicine University Medical Center Göttingen Georg August University Germany

Department of Pediatric Cardiology Emma Children's Hospital Amsterdam UMC Location AMC University of Amsterdam The Netherlands

Department of Pediatric Cardiology Erasmus MC Sophia Rotterdam The Netherlands

Department of Pediatrics BC Children's Hospital University of British Columbia Vancouver Canada

Department of Pediatrics Monroe Carell Jr Children's Hospital at Vanderbilt Vanderbilt University Medical Centre Nashville TN

Department of Pediatrics University of Alberta Edmonton Canada

Department of Pediatrics University of California Irvine

Departments of Cardiovascular Medicine Pediatric and Adolescent Medicine and Molecular Pharmacology and Experimental Therapeutics Divisions of Heart Rhythm Services and Pediatric Cardiology Windland Smith Rice Genetic Heart Rhythm Clinic and Windland Smith Rice Sudden Death Genomics Laboratory Mayo Clinic Rochester MN

Division of Cardiology Children's Mercy Hospital Kansas City MO

Division of Pediatric Cardiology Department of Pediatrics Norton Children's Hospital University of Louisville School of Medicine KY

Division of Pediatric Cardiology University of Utah Salt Lake City

Epidemiology and Data Science Amsterdam Public Health Methodology Amsterdam UMC Location AMC University of Amsterdam The Netherlands

European Reference Network for Rare Low Prevalence and Complex Diseases of the Heart ERN GUARD Heart

Heart and Lung Centre Helsinki University Hospital and Helsinki University Finland

Heart Centre Department of Cardiology Amsterdam UMC Location AMC University of Amsterdam The Netherlands

IWK Health Center Dalhousie University Halifax Canada

LIRYC Institute Bordeaux University Hospital Bordeaux University France

Medical Genome Center National Cerebral and Cardiovascular Center Suita Japan

ProCardio Center for Innovation Heart Vessel and Lung Clinic Oslo University Hospital Rikshospitalet Norway

Section of Cardiac Electrophysiology Division of Cardiology Department of Medicine Western University London Canada

Section of Genetics Department of Forensic Medicine Faculty of Medical Sciences University of Copenhagen Denmark

Service de Cardiologie et CRMR Maladies Cardiaques Héréditaires et Rares APHP Hôpital Bichat Université Paris Cité France

Sibley Heart Center Children's Healthcare of Atlanta GA

The Royal Children's Hospital Melbourne Australia

Unidad de Cardiopatías Familiares Muerte Súbita y Mecanismos de Enfermedad Instituto de Investigación Sanitaria La Fe Valencia Spain

Université de Nantes CHU Nantes CNRS INSERM L'institut du Thorax France

University of Alabama at Birmingham

University of Michigan Congenital Heart Center Ann Arbor

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