Ivabradine is a pure heart rate lowering agent. The SHIFT study has demonstrated that heart rate reduction using ivabradine in selected patients with chronic heart failure NYHA II to IV class, with heart failure with reduced ejection fraction (HFrEF), can significantly reduce hospitalisations due to worsening heart failure and prevent heart failure related death.

This advice applies to monitoring of pharmacotherapy in clinically stable patients; it does NOT apply to patients with intercurrent acute illness.

Ivabradine has recently been licensed for the management of chronic heart failure in patients in sinus rhythm and whose heart rate is ≥ 75 bpm in combination with standard therapy including betablocker therapy or when betablocker therapy is contraindicated or not tolerated.

Treatment for this indication should be recommended by specialist in heart failure.

The GP may prescribe following recommendation by the heart failure specialist.

The use of ivabradine is contraindicated in patients with Atrial Fibrillation.

To be initiated on recommendation of heart failure specialist.

• 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 blood pressure and pulse before initiation and after each change in dose.

• Once initiated the dose of ivabradine should be adjusted to achieve a heart rate ≥ 60bpm

Review within two weeks of initiation

• If the heart rate remains ≥ 60bpm, the dose should be increased to 7.5mg twice daily

• If the heart rate is less than 50bpm consider dose reduction or cessation of therapy

Adverse Effects

• Asymptomatic bradycardia is the most common adverse effect when using ivabradine in chronic heart failure; although a small proportion of patients will experience symptomatic bradycardia, for which dose reduction or cessation of therapy should be considered.

• Blurred vision and luminous phosphenes (sensations of brightness in fully maintained visual field) also commonly reported

Summary of Product Characteristics, Procoralan® www.medicines.org.uk/emc

Theresa A McDonagh et al, 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC, European Heart Journal, Volume 42, Issue 36, 21 September 2021, Pages 3599–3726.

Available at:  https://doi.org/10.1093/eurheartj/ehab368  (Accessed 07.03.22).

Correction published 21 December 2021, https://doi.org/10.1093/eurheartj/ehab670

Swedberg K, Komajda M, Böhm M et al, on behalf of the SHIFT Investigators. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study. Lancet 2010; 376 (9744):875-85

With thanks to the Sussex Heart Network, from whom these guidelines were adapted

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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