High-dose flecainide with low-dose ß-blocker therapy in catecholaminergic polymorphic ventricular tachycardia: A case report and review of the literature.

ABSTRACT

BACKGROUND: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is characterized by recurrent syncopes and sudden cardiac death triggered by sympathetic activation in young individuals without structural heart disease and a normal baseline electrocardiogram. There is reason to question whether the current expert consensus treatment recommendation, maximal tolerated ß-blockade alone or in combination with low-dose flecainide, is the optimal antiarrhythmic treatment strategy in CPVT, as high doses of ß-blockers may eventually lead to adverse side effects and ß-blocker discontinuation. Indeed, ß-blocker non-compliance accounts for around 5% of sudden cardiac deaths in CPVT patients. CASE REPORT Differing from the current recommendation, we present the first report of a CPVT patient successfully treated with high-dose flecainide and minimal ß-blockade. This combination resulted in complete suppression of ventricular arrhythmias during exercise stress tests and Holter monitoring and was well tolerated without any side effects. We review the current literature on ß-blocker non-compliance-related sudden cardiac death in CPVT, summarize the in vitro and in vivo data on flecainide therapy in CPVT, and discuss the rationale of our antiarrhythmic approach.<Learning objective: This case illustrates typical features of CPVT including the therapeutic management of a young CPVT patient with poor ß-blocker tolerance at normal dosages. In this setting, high-dose flecainide combined with minimal ß-blockade may (1) result in complete antiarrhythmic response and may (2) improve the antiarrhythmic drug-compliance thereby reducing the risk of non-compliance-related sudden cardiac death.>.