Do Imdur (isosorbide mononitrate) or Entresto (sacubitril/valsartan) lower heart rate?

Heart Rate Lowering Effects of Imdur and Entresto

Neither Imdur (isosorbide mononitrate) nor Entresto (sacubitril/valsartan) are primarily indicated for heart rate reduction, though Entresto may have a modest effect on heart rate in some patients with heart failure.

Imdur (isosorbide mononitrate)

• Imdur is a sustained-release nitrate preparation used for treatment of chronic stable angina pectoris 1
• Unlike beta-blockers or calcium channel blockers, Imdur does not have significant heart rate lowering properties 1
• Imdur works through vasodilation, which may actually cause a slight reflex tachycardia in some patients rather than reducing heart rate 1
• The NEAT-HFpEF trial showed that isosorbide mononitrate did not demonstrate beneficial effects on activity levels, quality of life, exercise tolerance, or NT-proBNP levels in heart failure patients with preserved ejection fraction 2

Entresto (sacubitril/valsartan)

• Entresto is an angiotensin receptor neprilysin inhibitor (ARNI) indicated for heart failure with reduced ejection fraction (HFrEF) 3, 4
• Entresto works through angiotensin receptor blockage via valsartan as well as neprilysin inhibition with sacubitril 3
• While not primarily a heart rate lowering medication, Entresto may have modest effects on heart rate in some patients through its effects on the cardiovascular system 4
• In the PARAGON-HF trial, sacubitril-valsartan compared with valsartan did not achieve a significant reduction in the primary composite endpoint of cardiovascular death or total heart failure hospitalizations in patients with HFpEF 2

Medications That Do Lower Heart Rate

For comparison, medications that are known to effectively lower heart rate include:

• Beta-blockers (such as metoprolol, carvedilol, atenolol):

  • First-line agents for heart rate control in atrial fibrillation and other conditions requiring rate control 2
  • Achieve specified heart rate endpoints in approximately 70% of patients compared with 54% with calcium channel blockers 2
  • Should be initiated cautiously in patients with heart failure who have reduced ejection fraction 2

• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem):

  • Effective for heart rate control, decreasing heart rate both at rest (by 8-23 beats per minute) and during exercise (by 20-34 beats per minute) 2
  • Should be used cautiously or avoided in patients with heart failure due to systolic dysfunction because of their negative inotropic effects 2
  • May be preferred over beta-blockers in patients with bronchospasm or chronic obstructive pulmonary disease 2

• Ivabradine:

  • An inhibitor of the "I-funny" or "If" channel, which is responsible for normal automaticity of the sinus node 2
  • Reduces the sinus node pacemaker activity, resulting in slowing of the heart rate 2
  • May be considered in patients with heart failure in sinus rhythm with a resting heart rate ≥70 bpm if symptomatic despite full heart failure treatment 2

Clinical Implications

• When heart rate control is needed, beta-blockers, non-dihydropyridine calcium channel blockers, or ivabradine should be considered rather than Imdur or Entresto 2
• For patients with heart failure requiring heart rate control, beta-blockers are generally preferred first-line agents 2
• In patients with atrial fibrillation and uncontrolled heart rate who cannot tolerate beta-blockers, digoxin may be used 2

Remember that medication selection should be based on the specific clinical scenario, comorbidities, and treatment goals rather than heart rate reduction alone 2.