What is the role of ivabradine (Ivabradine) in patients post-percutaneous coronary intervention (PCI)?

Role of Ivabradine in Post-PCI Patients

Ivabradine should be considered as add-on antianginal therapy only in post-PCI patients with left ventricular systolic dysfunction (LVEF <40%) and inadequate control of symptoms, but is not recommended for patients with preserved ejection fraction (LVEF >40%) and no clinical heart failure. 1

Indications for Ivabradine in Post-PCI Patients

• Ivabradine can be beneficial in post-PCI patients who have developed heart failure with reduced ejection fraction (HFrEF) with LVEF ≤35%, are in sinus rhythm with resting heart rate ≥70 bpm, and are already receiving guideline-directed medical therapy including maximum tolerated beta-blocker doses 1

• The primary benefit of ivabradine in these patients is reduction in heart failure hospitalizations rather than mortality improvement 1

• Ivabradine selectively inhibits the If current in the sinoatrial node, providing pure heart rate reduction without negative effects on blood pressure, myocardial contractility or intracardiac conduction 1, 2

Patient Selection Algorithm

1. First, identify post-PCI patients with:

   • Symptomatic heart failure (NYHA class II-III) 1
   • LVEF ≤35% 1
   • Sinus rhythm (not atrial fibrillation) 1
   • Resting heart rate ≥70 bpm 1
   • Already on maximum tolerated beta-blocker therapy 1

2. Do not use ivabradine in post-PCI patients with:

   • LVEF >40% and no clinical heart failure 1
   • Recent myocardial infarction (within 2 months) 1
   • Atrial fibrillation or predominant ventricular pacing 1

Evidence for Specific Post-PCI Scenarios

• Post-PCI with stable angina: Ivabradine combined with beta-blockers can reduce weekly angina attacks, nitrate consumption, and improve quality of life in patients with persistent angina after PCI 3

• Post-PCI with recent STEMI: In patients with impaired left ventricular function after reperfused anterior STEMI, ivabradine started 12 hours after PCI may improve left ventricular remodeling with increased ejection fraction and reduced end-systolic and end-diastolic volumes 4, 5

• Post-PCI with residual myocardial ischemia: Ivabradine can improve ischemic threshold, chronotropic reserve, and diastolic function in patients with residual angina after PCI 6

Important Clinical Considerations

• Beta-blockers should be optimized to maximum tolerated doses before considering ivabradine, given their well-proven mortality benefits 1

• Ivabradine should not be combined with non-dihydropyridine calcium channel blockers or other strong CYP3A4 inhibitors 1

• Target heart rate should be <60 bpm when using ivabradine for optimal results 5

• Typical starting dose is 5 mg twice daily, which can be adjusted based on heart rate response 3, 6

Potential Pitfalls and Caveats

• Only 25% of patients in the pivotal SHIFT trial were on optimal doses of beta-blocker therapy, which may limit generalizability to patients truly maximized on beta-blockers 1

• Ivabradine has no proven mortality benefit in post-PCI patients; its benefit is primarily reduction in heart failure hospitalizations 1

• Patients with paroxysmal atrial fibrillation should be monitored closely as ivabradine is only effective in sinus rhythm 1

• Drug interactions with statins are minimal, but patients should still be monitored for potential adverse effects 1