Can Ranexa (ranolazine) be used in patients with heart failure?

From the Guidelines

Ranolazine (Ranexa) is not recommended for use in heart failure, as it is primarily approved for treating chronic angina and its mechanism of action does not specifically address the pathophysiology of heart failure. The most recent and highest quality study, the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1, does not mention ranolazine as a recommended treatment for heart failure. Instead, it highlights the use of ACE inhibitors, beta-blockers, diuretics, aldosterone antagonists, and SGLT2 inhibitors as standard treatments for heart failure, depending on the type and severity of the condition. Ranolazine works by inhibiting the late sodium current in cardiac cells, which improves calcium handling and reduces myocardial oxygen demand, making it effective for angina but not specifically beneficial for heart failure.

Some key points to consider when evaluating the use of ranolazine in heart failure include:

• The lack of evidence supporting its use in heart failure management, as noted in the 2022 AHA/ACC/HFSA guideline 1
• The potential risks associated with ranolazine, such as QT interval prolongation, which may be particularly concerning in patients with heart failure
• The availability of alternative treatments that have been shown to improve outcomes in patients with heart failure, such as those listed in the 2022 AHA/ACC/HFSA guideline 1
• The importance of using caution when prescribing ranolazine in patients with certain conditions, including liver cirrhosis and prolonged QT interval, as well as when taking medications that inhibit CYP3A enzymes, as noted in earlier studies 1.

Overall, while ranolazine may have some potential benefits in specific populations, the current evidence does not support its routine use in heart failure management, and its use should be avoided in favor of established treatments that have been shown to improve morbidity, mortality, and quality of life in patients with heart failure.

From the FDA Drug Label

1. 8 Use in Patients with Heart Failure Heart failure (NYHA Class I to IV) had no significant effect on ranolazine pharmacokinetics. Ranolazine Extended-Release Tablets had minimal effects on heart rate and blood pressure in patients with angina and heart failure NYHA Class I to IV. No dose adjustment of Ranolazine Extended-Release Tablets is required in patients with heart failure.

• Ranexa (ranolazine) can be used in patients with heart failure.
• No dose adjustment is required in patients with heart failure, as it had no significant effect on ranolazine pharmacokinetics and had minimal effects on heart rate and blood pressure 2.

From the Research

Use of Ranexa in Patients with Heart Failure

• Ranolazine (Ranexa) is a novel antianginal and anti-ischemic agent that has been approved for the treatment of chronic stable angina pectoris 3, 4.
• The efficacy and tolerability of ranolazine were not affected by comorbid conditions, including old age, heart failure (HF), or diabetes mellitus 3, 4.
• Ranolazine may be used in patients with heart failure, as it does not have significant effects on heart rate or blood pressure, which can be beneficial in this patient population 5, 6.
• However, it is essential to note that ranolazine is not approved for the treatment of unstable angina, silent ischemia, or cardiac arrhythmias, and its use in these conditions should be approached with caution 5.

Key Considerations

• Ranolazine has been shown to be effective in improving exercise duration and reducing symptoms of angina in patients with chronic stable angina pectoris 3, 7, 4.
• The drug has a favorable safety profile, with minimal side effects, and is metabolized mainly in the liver and cleared by the kidney 7.
• Patients with impaired hepatic or renal function should be treated with caution when using ranolazine 7.
• Further studies are needed to determine the long-term effects of ranolazine on morbidity and mortality in patients with ischemic heart disease 3, 4.