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Katheria A, Kapoor A, Sahu A, Raut K, Khare H, Khanna R, Kumar S, Garg N, Tewari S. A pilot study evaluating the role of ivabradine for rate control in patients with rheumatic atrial fibrillation. Indian Heart J 2023; 75:376-382. [PMID: 37666416 PMCID: PMC10568053 DOI: 10.1016/j.ihj.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/06/2023] Open
Abstract
OBJECTIVES Ivabradine may have a role in rate control of atrial fibrillation (AF) due to effects on HCN channels in AV node. We studied role of Ivabradine in rate control of rheumatic AF. METHODS 80 patients, rheumatic AF, HR > 100 bpm (age 47 ± 11 yrs, AF duration 6.8 ± 2.9 years, rate 131 ± 16 bpm) on maximally tolerated ββ or CCB's, randomized to Ivabradine or escalated ββ/CCB. Ivabradine started @ 2.5 mg BD; increased to 5 mg BD if inadequate response at 1 week (failure to decrease HR < 10% vs baseline). After Holter at 1 month, dose escalated to 7.5 mg BD if needed. RESULTS Ivabradine resulted in significantly lower HR (81 ± 10 vs 99 ± 9) at 3 months and 6 months (79 ± 8 vs 94 ± 8, p < 0.001). Absolute reduction in HR: 56 ± 15 vs 31 ± 14 bpm and % change in HR: 41 ± 7 vs 24 ± 9%, both p < 0.00001). At 6 months, Ivabradine group had. 1Significantly lower NT Pro BNP (1168 vs 1314 pg/ml), higher 6 min walk distance (410 ± 47 vs 349 ± 54 m, all p < 0.001) 2Better symptom class (EHRA score 1: asymptomatic 84% vs 40%), improvement >1 EHRA class; baseline 60% vs 17% 3Better LA Strain (22.8 ± 2.8% vs 20.6 ± 2.5%) Ivabradine was well tolerated and there was no drug withdrawal. CONCLUSION Our data suggest that Ivabradine can be an option for rate control in rheumatic AF.
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Affiliation(s)
- Arpita Katheria
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India.
| | - Aditya Kapoor
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
| | - Ankit Sahu
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
| | - Kamlesh Raut
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
| | - Harshit Khare
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
| | - Roopali Khanna
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
| | - Sudeep Kumar
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
| | - Naveen Garg
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
| | - Satyendra Tewari
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
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Hackl B, Lukacs P, Ebner J, Pesti K, Haechl N, Földi MC, Lilliu E, Schicker K, Kubista H, Stary-Weinzinger A, Hilber K, Mike A, Todt H, Koenig X. The Bradycardic Agent Ivabradine Acts as an Atypical Inhibitor of Voltage-Gated Sodium Channels. Front Pharmacol 2022; 13:809802. [PMID: 35586063 PMCID: PMC9108390 DOI: 10.3389/fphar.2022.809802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/24/2022] [Indexed: 12/19/2022] Open
Abstract
Background and purpose: Ivabradine is clinically administered to lower the heart rate, proposedly by inhibiting hyperpolarization-activated cyclic nucleotide-gated cation channels in the sinoatrial node. Recent evidence suggests that voltage-gated sodium channels (VGSC) are inhibited within the same concentration range. VGSCs are expressed within the sinoatrial node and throughout the conduction system of the heart. A block of these channels thus likely contributes to the established and newly raised clinical indications of ivabradine. We, therefore, investigated the pharmacological action of ivabradine on VGSCs in sufficient detail in order to gain a better understanding of the pro- and anti-arrhythmic effects associated with the administration of this drug. Experimental Approach: Ivabradine was tested on VGSCs in native cardiomyocytes isolated from mouse ventricles and the His-Purkinje system and on human Nav1.5 in a heterologous expression system. We investigated the mechanism of channel inhibition by determining its voltage-, frequency-, state-, and temperature-dependence, complemented by a molecular drug docking to the recent Nav1.5 cryoEM structure. Automated patch-clamp experiments were used to investigate ivabradine-mediated changes in Nav1.5 inactivation parameters and inhibition of different VGSC isoforms. Key results: Ivabradine inhibited VGSCs in a voltage- and frequency-dependent manner, but did not alter voltage-dependence of activation and fast inactivation, nor recovery from fast inactivation. Cardiac (Nav1.5), neuronal (Nav1.2), and skeletal muscle (Nav1.4) VGSC isoforms were inhibited by ivabradine within the same concentration range, as were sodium currents in native cardiomyocytes isolated from the ventricles and the His-Purkinje system. Molecular drug docking suggested an interaction of ivabradine with the classical local anesthetic binding site. Conclusion and Implications: Ivabradine acts as an atypical inhibitor of VGSCs. Inhibition of VGSCs likely contributes to the heart rate lowering effect of ivabradine, in particular at higher stimulation frequencies and depolarized membrane potentials, and to the observed slowing of intra-cardiac conduction. Inhibition of VGSCs in native cardiomyocytes and across channel isoforms may provide a potential basis for the anti-arrhythmic potential as observed upon administration of ivabradine.
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Affiliation(s)
- Benjamin Hackl
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Peter Lukacs
- ELKH, Plant Protection Institute, Centre for Agricultural Research, Martonvásár, Hungary
| | - Janine Ebner
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Krisztina Pesti
- Department of Biochemistry, ELTE Eötvös Loránd University, Budapest, Hungary
- Semmelweis University, School of Ph.D. Studies, Budapest, Hungary
| | - Nicholas Haechl
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Mátyás C Földi
- ELKH, Plant Protection Institute, Centre for Agricultural Research, Martonvásár, Hungary
- Department of Biochemistry, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Elena Lilliu
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Klaus Schicker
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Helmut Kubista
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Karlheinz Hilber
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Arpad Mike
- ELKH, Plant Protection Institute, Centre for Agricultural Research, Martonvásár, Hungary
- Department of Biochemistry, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Hannes Todt
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Xaver Koenig
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
- *Correspondence: Xaver Koenig,
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Ivabradine and Atrial Fibrillation: A Meta-analysis of Randomized Controlled Trials. J Cardiovasc Pharmacol 2021; 79:549-557. [PMID: 34983905 DOI: 10.1097/fjc.0000000000001209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/20/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT This was a meta-analysis of randomized control trials (RCTs) to evaluate the effect of ivabradine on the risk of atrial fibrillation (AF) as well as its effect on the ventricular rate in patients with AF. The PubMed, EMBASE, Cochrane Controlled Trials Register, and other databases were searched for RCTs of ivabradine. Thirteen trials with 37,533 patients met the inclusion criteria. The incidence of AF was significantly higher in the ivabradine treatment group than in the control group (odds ratio (OR), 1.23; 95% confidence interval (CI), 1.08-1.41), although it was reduced after cardiac surgery (OR, 0.70; 95% CI, 0.23-2.12). Regarding left ventricular ejection fraction (LVEF), ivabradine increased the risk of AF in both LVEF >40% (OR, 1.42; 95% CI, 1.24 to 1.63) and LVEF ≤40% subgroups (OR, 1.16; 95% CI, 0.98-1.37). The risk of AF was increased by both small and large cumulative doses of ivabradine (small cumulative dose: OR, 3.00; 95% CI, 0.48 to 18.93; large cumulative dose: OR, 1.05; 95% CI, 0.83-1.34). Furthermore, ivabradine may reduce the ventricular rate in patients with AF. In conclusion, we found that both large and small cumulative doses of ivabradine were associated with an increased incidence of AF, and the effect was more marked in the LVEF >40% subgroup. Nevertheless, ivabradine therapy is beneficial for the prevention of post-operative AF. Furthermore, ivabradine may be effective in controlling the ventricular rate in patients with AF, although more RCTs are needed to support this conclusion.
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