Slowing heart rate with ivabradine: new treatment options

The burden of coronary artery disease (CAD) remains high and is the main cause of death and a major cause of morbidity. The treatment of patients with symptomatic CAD is aimed at preventing myocardial infarction and death, and reducing the symptoms of angina and occurrence of myocardial ischaemia. Significant evidence shows that elevated heart rate plays an important role in triggering ischaemic events in patients with CAD and is an important predictor of cardiovascular morbidity and mortality. Ivabradine is a potent anti-anginal agent which works by specifically lowering heart rate. Its antianginal and anti-ischaemic efficacy has been established in a number of randomized placebo-controlled trials, ivabradine being non-inferior to beta-blockers and to calcium antagonists. These trials have also shown that ivabradine is well tolerated and can be safely combined with other cardiovascular agents. The ASSOCIATE study showed that ivabradine provides significant heart rate reduction and improvement in all exercise test criteria in patients with stable angina receiving the beta-blocker atenolol. In addition to its effects on myocardial ischemia and anginal symptoms, ivabradine has the potential to improve clinical outcomes in patients with limiting angina or in patients with a heart rate above 70 b.p.m. as suggested in the BEAUTIFUL trial. In summary, ivabradine is a potent anti-anginal agent, which can be used alone (when beta-blockers are contraindicated or not tolerated) or in combination with beta-blockers, with excellent tolerability.