What is the recommended dosage and usage of ivabradine for patients with heart failure or inappropriate sinus tachycardia?

From the Guidelines

Ivabradine should be initiated at 5 mg twice daily for heart failure patients with a resting heart rate ≥70 beats per minute despite optimal beta-blocker therapy, with a maximum dose of 7.5 mg twice daily and a minimum dose of 2.5 mg twice daily, as supported by the SHIFT trial 1. The dosage and usage of ivabradine for patients with heart failure or inappropriate sinus tachycardia can be guided by the following key points:

• For heart failure patients, ivabradine is typically started at 5 mg twice daily, with adjustments based on heart rate response after 2 weeks, as indicated in the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1.
• The maximum dose is 7.5 mg twice daily, and the minimum dose is 2.5 mg twice daily, as recommended in the 2015 ACC/AHA/HRS guideline 1.
• 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 suggested by the 2015 ACC/AHA/HRS guideline 1.
• Ivabradine should be taken with meals to reduce the risk of visual side effects like phosphenes, as noted in the study by 1.
• Heart rate should be monitored regularly, and the dose should be reduced if heart rate falls below 50 beats per minute or if symptoms of bradycardia occur, as recommended in the study by 1.
• Ivabradine works by selectively inhibiting the If current in the sinoatrial node, slowing heart rate without affecting blood pressure or cardiac contractility, making it particularly valuable for heart failure patients who cannot tolerate beta-blockers or who remain symptomatic despite optimal beta-blocker therapy, as explained in the study by 1.
• The medication should be avoided in patients with severe hepatic impairment, pacemaker-dependent rhythm, or concomitant use of strong CYP3A4 inhibitors, as warned in the study by 1. Some key considerations for the use of ivabradine include:
• Monitoring for signs of bradycardia, such as dizziness or fainting, and adjusting the dose accordingly, as recommended in the study by 1.
• Avoiding concomitant use with other medications that can exacerbate bradycardia, such as beta blockers or non-dihydropyridine calcium channel blockers, as cautioned in the study by 1.
• Regularly assessing the patient's heart rate and adjusting the dose to maintain a heart rate between 50-100 beats per minute, as suggested in the study by 1. Overall, ivabradine is a valuable treatment option for patients with heart failure or inappropriate sinus tachycardia, offering a unique mechanism of action that can help improve symptoms and reduce the risk of hospitalization, as demonstrated in the SHIFT trial 1.

From the Research

Dosage and Usage of Ivabradine

The recommended dosage and usage of ivabradine for patients with heart failure or inappropriate sinus tachycardia vary based on the specific condition and patient response.

• For inappropriate sinus tachycardia, ivabradine can be initiated at 5 mg twice daily and increased to 7.5 mg twice daily after one week, as seen in a study published in the Cardiology journal 2.
• In another study published in Naunyn-Schmiedeberg's archives of pharmacology, ivabradine was given at a dose of 5-7.5 mg twice daily to patients with symptomatic inappropriate sinus tachycardia 3.
• A study published in Wiener klinische Wochenschrift used a dose of 15 mg per day for patients with inappropriate sinus tachycardia 4.

Heart Failure

For patients with heart failure, ivabradine is currently licensed for use in those with symptomatic heart failure with reduced ejection fraction and a heart rate persistently at least 70 beats per minute in spite of otherwise optimal prognostic heart failure pharmacotherapy 5.

• In a retrospective analysis of 29 consecutive patients treated for acute heart failure, ivabradine was initiated during hospitalization and showed a significant reduction in heart rate without episodes of significant bradycardia or hypotension 6.
• The therapeutic role of ivabradine in heart failure is further discussed in a review article published in Therapeutic advances in chronic disease, which examines the mechanism of action of ivabradine and evaluates the clinical trials underpinning its application in heart failure 5.

Key Findings

Key findings from the studies include:

• Ivabradine significantly reduces maximum and mean heart rate in patients with inappropriate sinus tachycardia 2, 3, 4.
• Ivabradine is well tolerated in patients with acute heart failure and represents an attractive option, especially when there is excessive catecholamine-related tachycardia 6.
• Ivabradine appears effective and safe in patients with symptomatic inappropriate sinus tachycardia 3.