Treatment of angina in patients in normal sinus rhythm
▶BY MOUTH
▶Adult 18–74 years: Initially 2.5–5 mg twice daily for
3–4 weeks, then increased if necessary up to 7.5 mg
twice daily, dose to be increased gradually; reduced if
not tolerated to 2.5–5 mg twice daily, heart rate at rest
should not be allowed to fall below 50 beats per
minute, discontinue treatment if no improvement in
symptoms within 3 months
▶Adult 75 years and over: Initially 2.5 mg twice daily for
3–4 weeks, then increased if necessary up to 7.5 mg
twice daily, dose to be increased gradually; reduced if
not tolerated to 2.5–5 mg twice daily, heart rate at rest
should not be allowed to fall below 50 beats per
minute, discontinue treatment if no improvement in
symptoms within 3 months
Mild to severe chronic heart failure
▶BY MOUTH
▶Adult 18–74 years: Initially 5 mg twice daily for 2 weeks,
then increased if necessary to 7.5 mg twice daily;
reduced if not tolerated to 2.5–5 mg twice daily, heart
rate at rest should not be allowed to fall below 50 beats
per minute
▶Adult 75 years and over: Initially 2.5 mg twice daily for
2 weeks, then increased if necessary up to 7.5 mg twice
daily, dose to be increased gradually; reduced if not
tolerated to 2.5–5 mg twice daily, heart rate at rest
should not be allowed to fall below 50 beats per minute
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DUE TO INTERACTIONS
▶Manufacturer advises reduce initial dose to 2.5 mg
twice daily with concurrent use of moderate CYP3A4
inhibitors (except diltiazem, erythromycin and
verapamil where concurrent use is contra-indicated).
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Acute myocardial infarction.
cardiogenic shock. congenital QT syndrome. do not
initiate for angina if heart rate below 70 beats per minute.
do not initiate for chronic heart failure if heart rate below
75 beats per minute. immediately after cerebrovascular
accident. patients dependent on pacemaker. second- and
third-degree heart block. severe hypotension. sick-sinus
syndrome. sino-atrial block. unstable angina. unstable or
acute heart failure
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Atrial fibrillation or other arrhythmias
(treatment ineffective). elderly. in angina, consider
stopping if there is no or limited symptom improvement
after 3 months. intraventricular conduction defects. mild
to moderate hypotension (avoid if severe). retinitis
pigmentosa
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NICE decisions
▶Ivabradine for the treatment of chronic heart failure
(November 2012) NICE TA267
Ivabradine, in combination with standard therapy
including a beta-blocker (unless contra-indicated or not
tolerated), an ACE inhibitor, and an aldosterone
antagonist, is an option for treating mild to severe stable
chronic heart failure in patients who:
. have a left ventricular ejection fraction of 35%, and
. are in sinus rhythm with a heart rate of 75 beats per
minute
Ivabradine should be initiated only by a heart failure
specialist after 4 weeks of stable optimal standard therapy;
monitoring and dose titration should be carried out by a
heart failure specialist, or a GP with special interest in
heart failure, or by a heart failure specialist nurse.
www.nice.org.uk/guidance/ta267
Scottish Medicines Consortium (SMC) decisions
SMC No. 805/12
The Scottish Medicines Consortium has advised (October
2012) that ivabradine (Procoralan ®) is accepted for
restricted use within NHS Scotland in accordance with its
licensed indication for heart failure only if resting heart
rate remains 75 beats per minute despite optimal
standard therapy.
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