Beta-Blockers and Ivabradine in Chronic Heart Failure: From Clinical Trials to Clinical Practice

Abstract

Beta-blockers have become one of the cornerstones of treatment of patients with heart failure (HF) and depressed left ventricular function, but in clinical practice only 30-35% of patients achieve the therapeutic target dose as established in randomized clinical trials. Moreover, high resting heart rate (HR) has emerged as a simple but relevant risk factor for cardiovascular events, including coronary artery disease and HF; also, it was found to have an independent prognostic value in patients with HF. Evidence that HR could be considered a good parameter to evaluate the quality of treatment in patients with HF has been suggested; of note, many patients maintain a resting HR ≥70 beats per minute despite optimal beta-blocker therapy. In recent years, a new drug able to reduce HR, ivabradine, has been introduced in clinical practice, and its use in the clinical setting of HF patients has been recommended by current European Society of Cardiology (ESC) guidelines. Here we review the evidence of the prognostic role of HR in systolic HF and the potential relationship between HR lowering and the beneficial effects of beta-blockers; we will also analyze the reasons why an appropriate use of these drugs is seldom achieved in clinical practice, and review the evidence for the use of ivabradine in systolic HF in the clinical setting.

Characterizing Patients with Chronic Heart Failure in Community Care After Hospitalization: A Potential Role for Ivabradine

“…Namely, a meta‐analysis has shown that the survival benefit of beta‐blockers in CHF is significantly associated with the magnitude of heart rate reduction . However, possibly due to numerous comorbidities in patients with CHF and tolerance problems , beta‐blockers are often not up‐titrated to target doses and are frequently discontinued in CHF . This clearly suggests a clinical need for additional heart rate‐lowering therapy that is well tolerated and effective in CHF.…”

Treatment of Heart Failure in Real‐World Clinical Practice: Findings From the REFLECT‐HF Registry in Patients With NYHA Class II Symptoms and a Reduced Ejection Fraction

“…Thus, it appears likely that the combination of β‐blockers and ivabradine was used more frequently in patients with NYHA class III/IV symptoms than in patients with NYHA class II symptoms. Estimates suggest that in real‐life clinical practice, only 30% to 35% of patients attain the therapeutic target dose of β‐blockers, and, in addition, even in patients who receive optimal dose levels, an elevated heart rate is often observed . Given that a high heart rate has been identified as an independent predictor of cardiovascular events in patients with HF, increased use of the combination of β‐blockers and ivabradine may confer survival benefits …”

Nemaline myopathy and heart failure: role of ivabradine; a case report

“…Moreover, recent meta-analysis of beta-blockers trials in HF found that the magnitude of HR reduction was more important than the achievement of target dose in predicting improved outcome [ 22 , 23 ]. Notably, beta-blockers are generally well tolerated but side effects may occur which may require drug withdrawal or a dose reduction, as in the case of our patient [ 24 ].…”