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Microsoft word - ivabradine_in_chronic_hf_failure_nelcn.doc
Prescribing Ivabradine for Chronic Heart Failure
Local Trust Heart Failure Service
Ivabradine is a pure heart-rate lowering agent via it’s inhibition the If
channels in the sino-atrial node.
Recent data from the SHIFT study has demonstrated that heart rate reduction using Ivabradine in selected
patients with chronic heart failure can significantly reduce hospitalisations due to worsening heart failure
and prevent heart failure related death.
Ivabradine is not currently licensed for the management of chronic heart failure and should only be
initiated for this indication by specialist hospital or community-based heart failure teams
Selection of Patients
Ivabradine should be considered for patients that meet ALL the following criteria:
• Left ventricular systolic dysfunction with an ejection fraction of 35% and NYHA class II-IV
• On maximum tolerated dose of both ACE inhibitor and beta-blocker (unless contraindicated)
• In sinus rhythm, with a resting heart rate 70 beats per minute (bpm)
− Bradycardia (resting heart rate <60bpm)
− Sino-atrial block & 3rd degree AV-block
− Hypotension (avoid if BP < 90/50mmHg)
− Hepatic insufficiency (avoid if severe)
Commonly Used Interacting Drugs (See BNF for a full list of drug interactions)
- Amiodarone or disopyramide – increased risk of ventricular arrhythmias
- Macrolide antibiotics, particularly clarithromycin and erythromycin – avoid concomitant use
- Imidazole anti-fungals, particularly ketoconazole and itraconzole – avoid concomitant use
- Nelfinavir and ritonavir – avoid concomitant use
- Sotalol – increased risk of ventricular arrhythmias
- Calcium channel blockers, specifical y diltiazem and verapamil – avoid concomitant use
Initiation and monitoring:
Ivabradine should be initiated at a dose of 5mg twice daily.
If the patient is elderly or 5mg twice daily is not
tolerated, the dose can be reduced to 2.5mg twice daily.
Obtain baseline BP and pulse before initiation and after each change in dose.
if the heart rate remains 60bpm, the dose should be increased to 7.5mg twice daily
if the heart rate is between 50 and 60bpm, the dose should be maintained at 5mg twice daily
if the heart rate is less than 50 bpm consider dose reduction or cessation of therapy.
Asymptomatic bradycardia is the most common adverse effect when using Ivabradine in chronic heart failure;
although a smal proportion of patients wil experience symptomatic bradycardia, for which dose reduction or
cessation of therapy should be considered. Visual symptoms were also reported.
Ivabradine is still a black triangle drug and therefore all adverse effects should be reported to the CSM
using the yellow card system, even if well documented.
1. Summary of Product Characteristics, Procoralan® Updated 25/10/07Ivabradine (Procoralan®).
3. British National Formulary 54 September 2007
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