What is the use of Ivabradine (Corlanor)?

From the Guidelines

Ivabradine (CORLANOR) should be considered for patients with heart failure and reduced ejection fraction (LVEF ≤35%) who are in sinus rhythm with a resting heart rate ≥70 beats per minute, despite optimal beta-blocker therapy, as it has been shown to reduce hospitalizations and improve symptoms 1.

Key Considerations

• Ivabradine works by selectively inhibiting the If current in the sinoatrial node, slowing heart rate without affecting blood pressure or cardiac contractility.
• The typical starting dose is 5 mg twice daily, which can be adjusted to 2.5-7.5 mg twice daily based on heart rate response.
• The target is to achieve a resting heart rate of 50-60 beats per minute.
• Common side effects include bradycardia, visual brightness phenomena (phosphenes), and atrial fibrillation.
• It should not be used with strong CYP3A4 inhibitors or in patients with severe hypotension, sick sinus syndrome, or acute decompensated heart failure.
• Regular heart rate monitoring is essential, especially when initiating therapy or adjusting doses.

Specific Patient Populations

• In patients with left ventricular dysfunction and heart failure, ivabradine can be beneficial in addition to beta-blockers, as shown in the SHIFT trial 1.
• In patients with atrial fibrillation, ivabradine is contraindicated due to its ineffectiveness and potential to increase the incidence of atrial fibrillation 1.
• In patients with hypertension, beta-blockers and dihydropyridine calcium-channel blockers are preferred, and ivabradine can be considered in specific cases 1.

Clinical Decision-Making

• Ivabradine should be initiated after optimal beta-blocker therapy has been established, and the patient's resting heart rate remains ≥70 beats per minute.
• The decision to use ivabradine should be based on individual patient characteristics, including comorbidities and concomitant medications.
• Close monitoring of heart rate and adjustment of ivabradine dose as needed is crucial to minimize adverse effects and optimize benefits.

From the FDA Drug Label

• To reduce the risk of hospitalization for worsening heart failure in adult patients with stable, symptomatic chronic heart failure with reduced left ventricular ejection fraction. ( 1.1) The main use of ivabradine (CORLANOR) is to reduce the risk of hospitalization for worsening heart failure in adult patients with stable, symptomatic chronic heart failure and reduced left ventricular ejection fraction 2.

From the Research

Ivabradine (CORLANOR) Overview

• Ivabradine is a unique agent that reduces heart rate without affecting myocardial contractility or vascular tone, as it is a use-dependent inhibitor targeting the sinoatrial node 3.
• It is approved for use in the United States as an adjunct therapy for heart rate reduction in patients with heart failure with reduced ejection fraction.

Clinical Uses and Benefits

• Ivabradine has demonstrated improved clinical outcomes due to reduction in heart failure readmissions 3.
• It may also play a role in the treatment of patients with inappropriate sinus tachycardia, who often cannot tolerate beta-blockers and/or calcium channel blockers 3.
• In patients with heart failure with reduced ejection fraction and elevated heart rate, ivabradine has been shown to improve symptoms, quality of life, and global assessment 4.
• Ivabradine has also been found to reduce the combined endpoint of cardiovascular death and hospitalization for heart failure in these patients 4.

Comparison with Beta-Blockers

• The effect of ivabradine apart from beta-blockers is not entirely clear, but it has been found to significantly reduce heart rate, with its additional effect on heart rate appearing to be inversely correlated with the dose of beta-blocker 5.
• Ivabradine has been compared to beta-blockers in several studies, with some suggesting that it may be a useful alternative or addition to beta-blocker therapy in certain patients 6.

Guideline Recommendations

• Ivabradine is recommended in the updated guidelines for the management of heart failure in patients with reduced ejection fraction, particularly in those with elevated heart rate despite optimal medical therapy 7.
• The guidelines suggest that targeting heart rate may offer benefit when added to renin-angiotensin aldosterone antagonists and beta-blockers, and that ivabradine may be a promising new treatment option for lowering heart rate in select patients with chronic heart failure 7.