Propafenone Topic Review

Propafenone is a class IC antiarrhythmic drug that acts by blocking sodium channels and has no effect on the action potential.

It is not commonly used in modern clinical practice due to side effects, and should only be used in patients with a life-threatening irregular heartbeat. [National Library of Medicine 2018]. Common adverse effects associated with propafenone include new-onset or exacerbated heart failure (HF), atrioventricular block, drug-induced Brugada syndrome, atrial flutter, ventricular tachycardia, dizziness, dyspnea, fatigue, nausea, diarrhea, xerostomia, tremor, taste disturbances and blurred vision. [Al-Khatib SM, et al. J Am Coll Cardiol. 2017;e114; Joglar JA, et al. J Am Coll Cardiol. 2023;83a]

The success rate of a single dose of propafenone converting atrial fibrillation (AF) to sinus rhythm is 43% to 57%, compared with 17% to 29% for placebo. [Joglar JA, et al. J Am Coll Cardiol. 2023;84a]

The 2017 American Heart Association/American College of Cardiology/Heart Rhythm Society Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death states that propafenone should not be used (Class 3 recommendation: Harm) in patients with prior myocardial infarction (MI) or in patients with adult congenital heart disease with asymptomatic ventricular arrhythmias. [Al-Khatib SM, et al. J Am Coll Cardiol. 2017;e129,e171]

The 2023 ACC/AHA/HRS/American College of Clinical Pharmacy Guideline for the Diagnosis and Management of Atrial Fibrillation states that use of propafenone is reasonable (Class 2a recommendation) for long-term maintenance of sinus rhythm in patients with AF but no previous MI, no known or suspected significant structural heart disease and no ventricular scar or fibrosis. [Joglar JA, et al. J Am Coll Cardiol. 2023;85a] The guideline states propafenone should not be used (Class 3 recommendation: Harm) in patients with previous MI and/or significant structural heart disease including HF with left ventricular ejection fraction 40% or less. [Joglar JA, et al. J Am Coll Cardiol. 2023;85a]

Propafenone can be used with a “pill-in-the-pocket” approach. If documented to be successful and safe while hospitalized, propafenone can be used on an as-needed basis in the outpatient setting. Note that propafenone is hepatically cleared (not recommended with liver disease) while flecainide (another class IC agent) is renally cleared. This approach received a Class 2a recommendation in the 2023 AF guideline, with the note that, due to the potential for proarrhythmia, it is reasonable to receive the first dose in a facility that can provide continuous ECG monitoring. [Joglar JA, et al. J Am Coll Cardiol. 2023;82a,89a]

References:

• Al-Khatib SM, et al. J Am Coll Cardiol. 2017;doi:10.1016/j.jacc.2017.01.054.

• Joglar JA, et al. J Am Coll Cardiol. 2023;doi:10.1016/j.jacc.2023.08.017.

• National Library of Medicine. https://medlineplus.gov/druginfo/meds/a698002.html. Updated Jan. 15, 2018. Accessed May 1, 2024.