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Flecainide Pill-in-Pocket — RACP Adult Medicine MCQ

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ModerateCardiologyFlecainide Pill-in-PocketRACP Adult Medicine

A 45-year-old woman with paroxysmal AF (episodes lasting hours, self-terminating) is highly symptomatic despite rate control with bisoprolol. She has a structurally normal heart and no heart failure. CHA₂DS₂-VASc is 1. She wishes to pursue rhythm control. What is the most appropriate antiarrhythmic?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Flecainide pill-in-pocket

Paroxysmal AF with structurally normal heart (no LVH, no HF, no CAD) — flecainide (Class IC) pill-in-pocket is an appropriate strategy for infrequent episodes. For regular prophylaxis: flecainide (with a beta-blocker or CCB to prevent 1:1 flutter conduction) or sotalol. Amiodarone is reserved for structural heart disease due to its toxicity profile. Catheter ablation is increasingly recommended as first-line rhythm control (EARLY-AF, STOP-AF trials).

Reference: CSANZ – 2024 – AF; ESC 2024 AF