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Angina - stable - Management
Managing ivabradine
Who should avoid taking ivabradine?
- Ivabradine is contraindicated in:
- Acute myocardial infarction or unstable angina.
- Severe hypotension (blood pressure less than 90/50 mmHg).
- Heart failure (New York Heart Association class III or IV).
- Sino-atrial block or 3rd degree AV block.
- Severe hepatic insufficiency.
- Ivabradine should not be started in anyone with a resting heart rate less than 60 beats per minute.
- Ivabradine is contraindicated in women who are pregnant or breastfeeding because data are lacking to support its use in these women.
In depth
What adverse effects are associated with ivabradine, and how can they be managed?
- Visual disturbances, including luminous phenomena (phosphenes) and blurred vision, have been commonly reported in people taking ivabradine.
- Luminous phenomena occur in about 15% of people taking ivabradine, usually starting within the first 2 months of treatment and resolving either on continued treatment or on stopping treatment.
- People taking ivabradine should be advised to be careful when driving or using machines at times when there could be sudden changes in light intensity (especially when driving at night) if they experience luminous phenomena.
- Bradycardia is noted in about 4% of people taking ivabradine. Monitor heart rate closely within the first 2–3 months of treatment.
- Headache is a common adverse effect experienced by people taking ivabradine. This is usually transient and resolves within the first month of treatment.
In depth
What key drug interactions should I be aware of?
- CYP3A4 enzyme inhibitors (such as azole antifungals, macrolide antibiotics, and protease inhibitors) should not be given concomitantly with ivabradine. Concomitant administration of a CYP3A4 enzyme inhibitor may increase the plasma concentration of ivabradine, increasing the risk of bradycardia.
- Drugs which prolong the QT interval (such as quinidine, amiodarone, and erythromycin) should not be given concomitantly with ivabradine. QT prolongation may be exacerbated by the heart rate reduction experienced with ivabradine.
- Grapefruit can increase the plasma concentration of ivabradine up to two-fold. People should be advised not to eat grapefruit or drink grapefruit juice whilst taking ivabradine.
- Rate-limiting calcium-channel blockers: concomitant use of ivabradine with verapamil or diltiazem is not recommended, because it can result in excessive reduction of heart rate.
In depth
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