From the Guidelines
Ivabradine should be considered in patients with left ventricular systolic dysfunction and heart failure who are in sinus rhythm with a heart rate of 70 bpm or greater at rest, despite optimal beta-blockade, to reduce heart failure hospitalization and improve symptoms, as evidenced by the SHIFT trial 1.
Patient Selection
When selecting patients for ivabradine treatment, it is essential to consider the presence of left ventricular systolic dysfunction and heart failure, as well as the patient's heart rate and rhythm. Patients with atrial fibrillation should not be treated with ivabradine, as it is ineffective in this population and may even increase the incidence of atrial fibrillation 1.
Dosing and Administration
The typical starting dose of ivabradine is 5 mg twice daily, which can be adjusted after two weeks to a maximum of 7.5 mg twice daily or decreased to 2.5 mg twice daily based on heart rate response and tolerance. The target heart rate should be 50-60 beats per minute. Ivabradine works by selectively inhibiting the If current in the sinoatrial node, reducing heart rate without affecting blood pressure or cardiac contractility.
Monitoring and Side Effects
Patients should take ivabradine with meals, monitor their heart rate regularly, and be aware of common side effects including visual disturbances (phosphenes), bradycardia, and atrial fibrillation. Ivabradine should not be used in patients with severe liver impairment, resting heart rate below 70 beats per minute, or in combination with strong CYP3A4 inhibitors. Regular follow-up is essential to assess efficacy and adjust dosing as needed.
Clinical Guidelines
The use of ivabradine is supported by clinical guidelines, including the 2017 ACC/AHA/HFSa focused update on the management of heart failure, which recommends ivabradine as a treatment option for patients with symptomatic heart failure with reduced ejection fraction (HFrEF) who are receiving guideline-directed medical therapy, including a beta blocker at maximum tolerated dose, and who are in sinus rhythm with a heart rate of 70 bpm or greater at rest 1.
From the FDA Drug Label
Ivabradine tablets are a prescription medicine used: • to treat adults who have chronic (lasting a long time) heart failure, with symptoms, to reduce their risk of hospitalization for worsening heart failure. Ivabradine is a hyperpolarization-activated cyclic nucleotide-gated channel blocker indicated: • 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.
Ivabradine Use: Ivabradine is used to treat adults with chronic heart failure and symptoms, to reduce the risk of hospitalization for worsening heart failure 2, 2.
- Key Indications:
- Reduce the risk of hospitalization for worsening heart failure in adult patients with stable, symptomatic chronic heart failure with reduced left ventricular ejection fraction.
- Treat adults who have chronic heart failure, with symptoms, to reduce their risk of hospitalization for worsening heart failure. Important Considerations:
- Patients should take ivabradine tablets exactly as their doctor tells them, with food, 2 times each day 2, 2.
- Patients should not stop taking ivabradine tablets without talking with their doctor 2, 2.
From the Research
Ivabradine Use in Angina Pectoris
- Ivabradine is a selective pacemaker current inhibitor used in the management of patients with angina pectoris, reducing heart rate (HR) specifically 3.
- The drug has been shown to be a well-tolerated and effective anti-anginal agent, recommended as a second-line agent for relief of angina in guidelines 3.
- Elevated heart rate plays a major role in coronary artery disease, and ivabradine's mode of action involves selective and specific inhibition of the major pacemaker current in the sinoatrial node, resulting in pure heart rate reduction 4.
Efficacy and Safety of Ivabradine
- Ivabradine has been demonstrated to have anti-ischemic and antianginal efficacy in patients with stable angina pectoris, with improvements in exercise capacity and reductions in anginal symptoms 4, 5.
- The drug has been shown to be well-tolerated, with bradycardia rarely reported, and its benefits are independent of resting heart rate 5, 6.
- Ivabradine reduces myocardial oxygen demand and contributes to the restoration of oxygen balance, which has demonstrated a benefit in chronic cardiovascular disease 6.
Combination Therapy with Beta-Blockers
- Ivabradine may be valuable for tailoring early antianginal treatment when used in combination with beta-blockers for chronic stable angina inadequately controlled by beta-blockers 5.
- The combination of ivabradine and beta-blockers has been shown to consistently reduce HR, anginal symptoms, and short-acting nitrate consumption, with continued reductions for up to 4 months 5.
- Ivabradine's anti-ischemic efficacy and safety have been demonstrated to be comparable in patients with baseline resting HRs above and below the median, with significant improvements in exercise capacity relative to placebo 7.