Ivabradine Use in Refractory Unstable Angina: A Case Report

Abstract

In this report, we describe the clinical results of ivabradine use in a patient with a serious form of unstable angina. For this patient, it was proposed that no other therapeutic, pharmacologic or surgical, option was available. The patient is a 75-year-old woman who presented with repeated episodes of retrosternal chest pain. She notably had a history of type II diabetes mellitus treated by insulin for several years and complicated by diabetic macro-angiopathy. ECG tracings recorded during these episodes showed abnormalities of the lateral repolarization phase of ischaemic nature. There was no measured increase in cardiac enzymes. She was transferred to our CCU with a diagnosis of unstable angina. In our CCU, the patient was treated with nitrates, metoprolol, aspirin, clopidogrel and atorvastatin at maximal sustainable doses. Following persistent clinical-instrumental instability, she was subjected to coronary angiography. This study revealed severe multi-vessel coronary artery disease not amenable to surgery or angioplasty revascularization. In addition to the therapy already provided, a beta-blocker (metoprolol 50 mgx2/die) and diltiazem (30 mgx2/die) were added despite their potentially dangerous and adverse chronotropic effects. Despite this treatment, the patients heart rate remained high (between 80 and 100 beats/min). This heart rate appeared to be the main driving cause of her anginal symptoms. At this point, the use of ivabradine seemed the only option, even though use would be off-label compared to current indications for the drugs use. We started with a low dose of 2.5 mg/b.i.d. and titrated up to 5 mg b.i.d. As we titrated, we witnessed a gradual reduction in heart rate. A consequent stabilization of her clinical pattern progressed into an almost unexpected asymptomatic state. After about a week of clinical observation, the patient recovered. After three months, she remains asymptomatic.

Ivabradine Use in Heart Failure After Myocardial Infarction Can Help with the Titration of the Dose of ARB/ACEI or β-Blockers: A Case Report

“…decreasing HR while avoiding the adverse effects of more traditional antianginal agents (β-blockers and calcium channel antagonists) (7,8). Ivabradine used to treat heart failure not only reduces HR but also prolongs diastolic perfusion time, improves coronary blood flow, increases exercise capacity, and may even increase stroke volume, which may underlie its beneficial cardiac effects (9).…”

Refractory Angina—An Overview and Recent Trends

“…11 Ivabradine reduces myocardial oxygen demand by its negative chronotropic effect without any effect on cardiac inotropy, and it has anti-ischemic and antianginal efficacy either as monotherapy or along with atenolol. 12…”

Attenuation of Haemodynamic Response to Laryngoscopy and Endotracheal Intubation Using Intra-Oral Ivabradine: A Clinical Study

“…5 Ivabradine reduces the heart rate without producing a precipitous fall in blood pressure; hence it is useful in patients with angina pectoris, coronary artery disease (CAD), cardiac failure, obstructive cardiomyopathies and in all conditions where the myocardial oxygen supply is endangered and myocardial oxygen demand is increased. 6,7 By not allowing the heart rate to increase, Ivabradine conserves the oxygen reserves of the myocardium and reduces the myocardium oxygen demand. 8 Hence in every aspect Ivabradine is an ideal drug to be used during general anesthesia procedures in view of its multiple benefits on the myocardium.…”