Heart rate-lowering efficacy and respiratory safety of ivabradine in patients with obstructive airway disease: a randomized, double-blind, placebo-controlled, crossover study

Effects of Ivabradine on Right Ventricular Systolic Function in Patients With Chronic Obstructive Pulmonary Disease and Cor Pulmonale

Cor pulmonale is a clinical syndrome associated with pulmonary hypertension, frequently complicated by congestive heart failure, commonly caused by chronic obstructive pulmonary disease (COPD). Most patients with cor pulmonale have tachycardia. However, heart rate (HR) reduction represents a primary treatment goal to improve the survival and quality of life in these patients. Ivabradine can selectively slow HR at rest and during exercise. In this prospective study, we tested the hemodynamic effects, invasively determined using right-sided cardiac catheterization, of reducing HR with ivabradine. We selected 18 patients (13 men [72.2%], mean age 67 ± 10 years) with COPD and cor pulmonale, presenting with sinus tachycardia. All patients performed clinical evaluation, electrocardiogram, spirometry, echocardiogram, 6-minute walking distance, and right-sided cardiac catheterization within 1 month of enrollment. All tests were repeated after 6 months of ivabradine treatment (median assumed dose 11.9 mg/die). We noticed a significant decrease of HR (from 98 ± 7 to 77 ± 8 beats/min, p = 0.0001), with a concomitant reduction of the congestion index (from 25.9 ± 5.1 to 19.4 ± 5.7 mm Hg, p = 0.001), and the consequent improvement of the right ventricular systolic performance (right ventricular stroke volume augmented from 56.7 ± 7.9 to 75.2 ± 8.6 ml/beat, p = 0.0001). This allows an improvement in clinical status and exercise tolerance (Borg scale score decreased from 5.2 ± 1.4 to 4.1 ± 1.3, p = 0.01 and the 6-minute walking distance increased to 252 ± 65 to 377 ± 59 m, p = 0.001). In conclusion, HR reduction significantly improves hemodynamic and clinical status of patients with tachycardia affected by COPD and cor pulmonale.

Beyond Heart Failure and Ischemic Heart Disease: A Scoping Review of Novel Uses of Ivabradine in Adults

Ivabradine lowers heart rate by inhibiting the hyperpolarization-activated current in pacemaker cells, and its use for the treatment of heart failure (HF) and ischemic heart disease (IHD) is well described. Ivabradine may be an attractive treatment option for other conditions for which a reduction in heart rate is desirable but less is known about its role in these settings. The primary objective was to perform a scoping review summarizing the literature evaluating novel uses for ivabradine other than HF and IHD in adults. PubMed and EMBASE were searched for articles for all dates through September 2019. Search strategies combined terms generic, commercial/trade, and international names for ivabradine. Manual search of references was also performed to identify additional articles. Studies were included if they were published in English, evaluated the efficacy of ivabradine for indications other than HF or IHD in patients aged 18 years or older, and the primary outcome included clinically relevant end points. Articles were screened first by title and abstract followed by full-text screening of the remaining articles. After removal of duplicates, 1807 records were screened for inclusion and 84 studies were included in this scoping review. Novel uses of ivabradine were reported for various tachyarrhythmias, valvular heart disease, premedication for coronary computed tomography angiography, perioperative risk reduction, sepsis with and without multi-organ dysfunction syndrome, cor pulmonale, reactive airway disease, and erectile dysfunction. This scoping review identified several potential novel uses for ivabradine in adults. This review may help to identify existing gaps where further research is needed to elucidate the role of ivabradine for indications beyond HF and IHD.

Angina and chronic obstructive pulmonary disease: facing the perfect storm

The association of chronic obstructive pulmonary disease (COPD) and ischaemic heart disease (IHD) is challenging both in terms of prognosis and of pharmacological treatment. An 83-year-old Caucasian male patient has chronic kidney disease, COPD, previous myocardial infarction, coronary artery bypass graft with left internal mammary artery (LIMA) on left anterior descending (LAD), saphenous vein graft (SVG) on obtuse marginal (OM)1 and on right coronary artery, and percutaneous coronary intervention (PCI) on LAD (occlusion of LIMA) and on SVG for OM1 (SVG critical stenosis). Recently, the patient complained worsening angina [Canadian Cardiovascular Society (CCS) III] and had residual ischaemia in the anterior wall after an unsuccessful attempt of PCI was performed on LAD for in-stent occlusion due to restenosis. Bisoprolol uptitration failed due to worsening of pulmonary function at spirometry. For this reason, ivabradine 5 mg b.i.d. was added to bisoprolol. Afterwards, the patient referred amelioration of symptoms and he is actually in CCS Class I. The control spirometry showed moderate obstruction comparable to his chronic situation. Patients with IHD and COPD often do not receive β-blockers due to the fear of adverse effects. However, cardioselective β-blockers do not worsen pulmonary function while they reduce mortality in COPD patients. In this setting, ivabradine could be extremely helpful in order to control symptoms since it is effective in patients with asthma and COPD, with no alteration in respiratory function or symptoms and improves exercise capacity and functional class in COPD patients.

Ivabradine: Evidence and current role in cardiovascular diseases and other emerging indications

Increased heart rate (HR) is associated with deleterious effects on several disease conditions. Chronic heart failure (CHF) is one of the cardiovascular diseases with recurrent hospitalization burden and an ongoing drain on health-care expenditure. Despite advancement in medicine, management of CHF remains a challenge to health-care providers. Ivabradine selectively and specifically inhibits the pacemaker I(f) ionic current which reduces the cardiac pacemaker activity. The main effect of ivabradine therapy is the substantial lowering of HR. It does not influence intracardiac conduction, contractility, or ventricular repolarization. As shown in numerous clinical studies, ivabradine improves clinical outcomes and quality of life and reduces the risk of death from heart failure (HF) or other cardiovascular causes. Recently updated HF guidelines recommend ivabradine as a class II indication for reduction of HF hospitalizations. Based on the principle of benefits of reduced HR, the ivabradine in patients with ischemic heart disease, sepsis, and multiple organ dysfunction syndrome has also been studied. It can also be a useful agent for HR reduction in patients with contraindications to use beta-blockers or those who cannot tolerate them. In this review, we provide an overview of efficacy and safety of ivabradine and its combination with currently recommended pharmacological therapy in different conditions.

β-Blockers, heart disease and COPD: current controversies and uncertainties

Treating people with cardiovascular disease and COPD causes significant clinician anxiety. β-Blockers save lives in people with heart disease, specifically postinfarction and heart failure. COPD and heart disease frequently coexist and people with both disorders have particularly high cardiovascular mortality. There are concerns about giving β-blockers to people with concomitant COPD that include reduced basal lung function, diminished effectiveness of emergency β-agonist treatments, reduced benefit of long-acting β-agonist treatment and difficulty in discriminating between asthma and COPD. β-Blockers appear to reduce lung function in both the general population and those with COPD because they are poorly selective for cardiac β1-adrenoceptors over respiratory β2-adrenoceptors, and studies have shown that higher β-agonist doses are required to overcome the β-blockade. COPD and cardiovascular disease share similar environmental risks and both disease states have high adrenergic and inflammatory activation. β-Blockers may therefore be particularly helpful in reducing cardiovascular events in this high-risk group. They may reduce the background inflammatory state, and inhibit the tachycardia and hypertension associated with both the endogenous adrenaline and high-dose β-agonist treatment associated with acute exacerbations of COPD. Some studies have suggested no increased and, at times, reduced mortality in patients with COPD taking β-blockers for heart disease. However, these are all observational studies and there are no randomised controlled trials. Potential ways to improve this dilemma include the development of highly β1-selective β-blockers or the use of non-β-blocking heart rate reducing agents, such as ivabridine, if these are proven to be beneficial in randomised controlled trials.

Comprehensive CT cardiothoracic imaging: a new challenge for chest imaging

In the past, thoracic and cardiac imaging were two distinct specialties of radiology. The technical evolution, however, has changed their boundaries with an important impact on CT imaging practices and has opened the new era of "cardiothoracic" imaging, due to the strong anatomic, mechanical, physiologic, physiopathologic, and therapeutic cardiopulmonary correlations. Modern thoracic radiologists can no longer avoid the assessment of heart and coronary arteries, as they used to do with earlier generations of CT scanner. The advent of ECG gating and state-of-art CT scanner faster rotation speed, high spatial and temporal resolution, high-pitch mode, shorter acquisition time, and dedicated cardiac reconstruction algorithms has opened new possibilities for chest imaging, integrating cardiac morphologic and even functional information within a diagnostic chest CT scan. The aim of this review is to briefly show and summarize the concept of integrated cardiothoracic imaging, which redefines the boundaries of chest CT imaging, opening the door to a new radiologic specialty.

Is there a role for ivabradine beyond its conventional use?

Results of recent clinical trials in patients with stable angina and chronic heart failure have successfully demonstrated a beneficial role of use of ivabradine in addition to the conventional therapy. Based on the results of these trials, the aim of our review was to give an overview of the literature about the use of ivabradine in clinical settings outside its usual purpose.

Risk-benefit assessment of ivabradine in the treatment of chronic heart failure

Heart rate is not only a major risk marker in heart failure but also a general risk marker. Within the last few years, it has been demonstrated that reduction of resting heart rate to <70 bpm is of significant benefit for patients with heart failure, especially those with impaired left ventricular systolic function. Ivabradine is the first innovative drug synthesized to reduce heart rate. It selectively and specifically inhibits the pacemaker I f ionic current, which reduces cardiac pacemaker activity. Therefore, the main effect of ivabradine therapy is a substantial lowering of heart rate. Ivabradine does not influence intracardiac conduction, contractility, or ventricular repolarization. According to the European Society of Cardiology guidelines, ivabradine should be considered in symptomatic patients (New York Heart Association functional class II-IV) with sinus rhythm, left ventricular ejection fraction ≤35%, and heart rate ≥70 bpm despite optimal treatment with a beta-blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and a mineralocorticoid receptor antagonist. As shown in numerous clinical studies, ivabradine improves clinical outcomes and quality of life and reduces the risk of death from heart failure or cardiovascular causes. Treatment with ivabradine is very well tolerated and safe, even at maximal recommended doses.

Clinical profiles and outcomes in patients with chronic heart failure and chronic obstructive pulmonary disease: an efficacy and safety analysis of SHIFT study

BACKGROUND

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) frequently coexist, with undefined prognostic and therapeutic implications. We investigated clinical profile and outcomes of patients with chronic HF and COPD, notably the efficacy and safety of ivabradine, a heart rate-reducing agent.

METHODS

6505 ambulatory patients, in sinus rhythm, heart rate ≥ 70 bpm and stable systolic HF were randomised to placebo or ivabradine (2.5 to 7.5mg bid). Multivariate Cox model analyses were performed to compare the COPD (n=730) and non-COPD subgroups, and the ivabradine and placebo treatment effects.

RESULTS

COPD patients were older and had a poorer risk profile. Beta-blockers were prescribed to 69% of COPD patients and 92% of non-COPD patients. The primary endpoint (PEP) and its component, hospitalisation for worsening HF, were more frequent in COPD patients (HRs f, 1.22 [p=0.006]; and 1.34 [p<0.001]) respectively, but relative risk was reduced similarly by ivabradine in both COPD (14%, and 17%) and non-COPD (18% and 27%) patients (p interaction=0.82, and 0.53, respectively). Similar effect was noted also for cardiovascular death. Adverse events were more common in COPD patients, but similar in treatment subgroups. Bradycardia occurred more frequently in ivabradine subgroups, with similar incidence in patients with or without COPD.

CONCLUSIONS

The association of COPD and HF results in a worse prognosis, and COPD represents a barrier to optimisation of beta-blocker therapy. Ivabradine is similarly effective and safe in chronic HF patients with or without COPD, and can be safely combined with beta-blockers in COPD.

Pharmacological treatment of chronic stable angina pectoris

Chronic stable angina is the most common manifestation of ischaemic heart disease in the developed world and is associated with impaired quality of life and increased mortality. The pathogenesis of stable angina is complex and often, albeit not always, involves flow-limiting epicardial coronary artery stenoses (atheromatous plaques) that reduce the ability of the coronary circulation to deliver appropriate blood supply to the myocardium. The coronary microcirculation can also play an important role. An imbalance between myocardial oxygen supply and metabolic oxygen demand causes the symptoms of angina pectoris and represents a major therapeutic target. Rational treatment requires a multi-faceted approach combining lifestyle changes, aggressive management of modifiable coronary artery disease risk factors, pharmacological therapy and myocardial revascularisation when appropriate. Despite modern therapies, many patients continue to suffer from angina. Several new anti-anginal drugs have been introduced that might allow more effective symptom control. These novel agents have specific mechanisms of action and fewer side effects compared to conventional drugs. The combined use of traditional and novel treatments is likely to increase the proportion of patients who are managed successfully with medical therapy alone. This article briefly reviews recent advances in the pharmacological management of chronic stable angina pectoris, highlighting how an understanding of the prevailing pathogenic mechanisms in the individual patient can aid appropriate selection of therapeutic strategies and improve clinical outcome.