From the Guidelines
Ivabradine is typically initiated at 5 mg twice daily for heart failure patients with a resting heart rate ≥70 beats per minute despite optimal beta-blocker therapy, and for inappropriate sinus tachycardia, treatment usually starts at 2.5-5 mg twice daily, with gradual titration based on symptom improvement and heart rate control, as recommended by the 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment 1.
Key Considerations
- The dose can be adjusted after two weeks based on heart rate response, with a maximum dose of 7.5 mg twice daily and a minimum dose of 2.5 mg twice daily.
- Ivabradine should be taken with meals to reduce the risk of visual side effects like phosphenes.
- Heart rate should be monitored regularly during treatment, and the dose should be reduced if heart rate falls below 50 beats per minute or if symptoms of bradycardia occur.
- Ivabradine works by selectively inhibiting the If current in the sinoatrial node, which slows heart rate without affecting blood pressure or cardiac contractility.
Important Safety Information
- Patients should be advised that common side effects include visual brightness, dizziness, and bradycardia, and they should avoid grapefruit juice which can increase drug levels.
- Contraindications to ivabradine include decompensated heart failure, severe hepatic impairment, and concomitant use of strong CYP3A4 inhibitors or inducers, as noted in the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1.
Clinical Evidence
- The SHIFT trial demonstrated the efficacy of ivabradine in reducing the composite endpoint of cardiovascular death or heart failure hospitalization in patients with heart failure, as reported in the 2012 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1.
- The 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure also recommends ivabradine for patients with symptomatic heart failure despite optimal therapy with ACE inhibitors, beta-blockers, and mineralocorticoid receptor antagonists 1.
From the FDA Drug Label
The recommended starting dose of ivabradine tablets is 5 mg twice daily with food. Assess patient after two weeks and adjust dose to achieve a resting heart rate between 50 and 60 beats per minute (bpm) as shown in Table 1. Thereafter, adjust dose as needed based on resting heart rate and tolerability. The maximum dose is 7.5 mg twice daily.
The recommended dosage and treatment plan for Ivabradine in patients with heart failure is to start with 5 mg twice daily and adjust the dose to achieve a resting heart rate between 50 and 60 beats per minute (bpm). The dose can be increased or decreased based on the patient's heart rate and tolerability, with a maximum dose of 7.5 mg twice daily.
- Key considerations for dosage adjustment include:
- Heart rate > 60 bpm: increase dose by 2.5 mg
- Heart rate 50 to 60 bpm: maintain dose
- Heart rate < 50 bpm or signs and symptoms of bradycardia: decrease dose by 2.5 mg 2
From the Research
Recommended Dosage and Treatment Plan for Ivabradine
The recommended dosage and treatment plan for Ivabradine in patients with heart failure or inappropriate sinus tachycardia are as follows:
- For heart failure patients, Ivabradine is recommended as an adjunct therapy for heart rate reduction in patients with heart failure with reduced ejection fraction, with a dosage of 5-7.5 mg twice a day 3, 4.
- For patients with inappropriate sinus tachycardia, Ivabradine has been successfully used with a dosage of 5-7.5 mg twice a day, resulting in significant reduction in heart rate and improvement in quality of life 5.
- The treatment plan for Ivabradine involves initiating therapy with a low dose and gradually increasing it as needed and tolerated, with regular monitoring of heart rate and clinical status 5, 4.
Clinical Indications and Efficacy
Ivabradine has been shown to be effective in:
- Reducing heart failure hospitalization and deaths in patients with heart failure with reduced ejection fraction 3.
- Normalizing heart rate and improving quality of life in patients with inappropriate sinus tachycardia 5.
- Controlling heart rate in patients with postural tachycardia syndrome (POTS) and tachyarrhythmia 6.
- Serving as an alternative to β-blockers in case of contraindications or intolerance in patients with heart failure with reduced ejection fraction and coronary artery disease 7, 6.
Safety and Tolerability
Ivabradine has been shown to be safe and well-tolerated in clinical trials, with no episodes of severe bradycardia or syncope reported 5.
- The most common adverse effects of Ivabradine include bradycardia, hypertension, and atrial fibrillation 7.
- Ivabradine has a unique mechanism of action that reduces heart rate without affecting myocardial contractility or vascular tone, making it a valuable treatment option for patients with heart failure or inappropriate sinus tachycardia 3, 7.