ESC Congress 2016 - 15D
Figure 4. Impact of Co-administration of ß-Blockers and
Ivabradine on Reducing Heart Rate
Table 2. Synergistic and Complementary Effects of ß-Blockers
and Ivabradine on Hemodynamics
through a multidisciplinary team, and ensures follow-up
visits within the first 7 days with a general practitioner
and within the first 14 days with a cardiologist.
AF, atrial fibrillation; LAA, left atrial appendage; NOAC, non-vitamin K antagonist oral
anticoagulant; OAC, oral anticoagulant; VKA, vitamin K antagonist.
Reprinted from Hidalgo FJ, Anguita M, Castillo JC, et al. Effect of early treatment
with ivabradine combined with beta-blockers versus beta-blockers alone in patients
hospitalised with heart failure and reduced left ventricular ejection fraction (ETHIC-AHF):
A randomised study. Int J Cardiol 2016;217:7-11. By permission of Elsevier.
A novel strategy to achieve lower HRs is the coadministration of a ß-blocker and ivabradine. The
ETHIC-AHF study showed that early initiation of ivabradine, rather than uptitration of ß-blockers alone, was
associated with a greater proportion of patients achieving the target HR at discharge, 28 days, and 4 months
(Figure 4).21 According to Prof Coats, this novel strategy
removes the risk of further decompensation and problems related to the uptitration of ß-blockers. Interestingly, in the co-administration group, the ejection fraction
was higher and the brain natriuretic peptides were lower
than in the control group. This strategy improves stability
in high-risk patients, stated Prof Coats.
Another benefit of the co-administration strategy is
achieving higher doses of the ß-blocker, compared with
uptitrating the ß-blocker alone, as shown in an uptitration study of carvedilol and ivabradine. Greater reductions in HR and improvement in ejection fraction were
also achieved.22 The differential impact of ß-blockers and
ivabradine on hemodynamics, thus their synergistic and
complementary roles, is summarized in Table 2.
An element in the overall strategy for optimizing HF
treatment is therapy to reduce HR, to a target of 50-60
bpm, with the use of guideline-directed therapies such
as a ß-blocker and/or ivabradine. All guideline-directed
pharmacologic and device therapies must be optimized to
target levels, as outlined in the 2016 ESC guideline for the
treatment and management of HF. Not to be overlooked
is the critical management of the vulnerable phase, thorough pre-discharge planning that ensures the readiness
of the patient for discharge by meeting the criteria set by
the ESC HF guidelines, that coordinates post-discharge
1. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the
diagnosis and treatment of acute and chronic heart failure of the European
Society of Cardiology (ESC)Developed with the special contribution of the
Heart Failure Association (HFA) of the ESC. Eur Heart J 2016;37:2129-200.
2. McMurray JJ, Packer M, Desai AS, et al, on behalf of the PARADIGM-HF
Investigators and Committees. Angiotensin-neprilysin inhibition versus
enalapril in heart failure. N Engl J Med 2014;371:993-1004.
3. Logeart D, Isnard R, Resche-Rigon M, et al. Current aspects of the spectrum
of acute heart failure syndromes in a real-life setting: the OFICA study. Eur J
Heart Fail 2013;15:465-76.
4. Böhm M, Swedberg K, Komajda M, et al, on behalf of the SHIFT Investigators. Heart rate as a risk factor in chronic heart failure (SHIFT): the association between heart rate and outcomes in a randomised placebo-controlled
trial. Lancet 2010;376:886-94.
5. Nanchen D, Leening MJ, Locatelli I, et al. Resting heart rate and the risk
of heart failure in healthy adults: the Rotterdam Study. Circ Heart Fail
6. Fosbol EL, Seibaek M, Brendorp B, et al, on behalf of the Danish Investigations and Arrhythmia ON Dofetilide Study Group. Long-term prognostic importance of resting heart rate in patients with left ventricular dysfunction in
connection with either heart failure or myocardial infarction: the DIAMOND
study. Int J Cardiol 2010;140:279-86.
7. Greene SJ, Vaduganathan M, Wilcox JE, et al, on behalf of the EVEREST Trial
Investigators. The prognostic significance of heart rate in patients hospitalized for heart failure with reduced ejection fraction in sinus rhythm: insights
from the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure:
Outcome Study With Tolvaptan) trial. JACC Heart Fail 2013;1:488-96.
8. 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;376:875-85.
9. Braunstein JB, Anderson GF, Gerstenblith G, et al. Noncardiac comorbidity
increases preventable hospitalizations and mortality among Medicare beneficiaries with chronic heart failure. J Am Coll Cardiol 2003;42:1226-33.
10.Al-Ahmad A, Rand WM, Manjunath G, et al. Reduced kidney function and
anemia as risk factors for mortality in patients with left ventricular dysfunction. J Am Coll Cardiol 2001;38:955-62.
11.Böhm M, Robertson M, Ford I, et al. Influence of cardiovascular and noncardiovascular co-morbidities on outcomes and treatment effect of heart rate
reduction with ivabradine in stable heart failure (from the SHIFT trial). Am J
12.Mancini GB, Etminan M, Zhang B, Levesque LE, FitzGerald JM, Brophy JM.
Reduction of morbidity and mortality by statins, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers in patients with chronic
obstructive pulmonary disease. J Am Coll Cardiol 2006;47:2554-60.
13.Hillege HL, Nitsch D, Pfeffer MA, et al, on behalf of the Candesartan in Heart
Failure: Assessment of Reduction in Mortality and Morbidity (CHARM)
Investigators. Renal function as a predictor of outcome in a broad spectrum
of patients with heart failure. Circulation 2006;113:671-8.
14.Ponikowski P, van Veldhuisen DJ, Comin-Colet J, et al, on behalf of the
CONFIRM-HF Investigators. Beneficial effects of long-term intravenous
iron therapy with ferric carboxymaltose in patients with symptomatic heart
failure and iron deficiency†. Eur Heart J 2015;36:657-68.
15.Ponikowski P, Filippatos G, Colet JC, et al, on behalf of the FAIR-HF Investigators. The impact of intravenous ferric carboxymaltose on renal function: an
analysis of the FAIR-HF study. Eur J Heart Fail 2015;17:329-39.
16.Basoor A, Doshi NC, Cotant JF, et al. Decreased readmissions and improved
quality of care with the use of an inexpensive checklist in heart failure. Congest Heart Fail 2013;19:200-6.
17.Komajda M, Böhm M, Borer JS, et al, on behalf of the SHIFT Investigators. Efficacy and safety of ivabradine in patients with chronic systolic heart failure
according to blood pressure level in SHIFT. Eur J Heart Fail 2014;16:810-6.
18.Flannery G, Gehrig-Mills R, Billah B, Krum H. Analysis of randomized
controlled trials on the effect of magnitude of heart rate reduction on clinical
outcomes in patients with systolic chronic heart failure receiving ß-blockers.
Am J Cardiol 2008;101:865-9.
19.Komajda M, Tavazzi L, Swedberg K, et al, on behalf of the SHIFT Investigators. Chronic exposure to ivabradine reduces readmissions in the vulnerable
phase after hospitalization for worsening systolic heart failure: a post-hoc
analysis of SHIFT. Eur J Heart Fail 2016;18:1182-9
20.den Hoed M, Eijgelsheim M, Esko T, et al. Identification of heart rate-associated loci and their effects on cardiac conduction and rhythm disorders. Nat
21.Hidalgo FJ, Anguita M, Castillo JC, et al. Effect of early treatment with
ivabradine combined with ß-blockers versus ß-blockers alone in patients
hospitalised with heart failure and reduced left ventricular ejection fraction
(ETHIC-AHF): A randomised study. Int J Cardiol 2016;217:7-11.
22.Bagriy AE, Schukina EV, Samoilova OV, et al. Addition of ivabradine to
ß-blocker improves exercise capacity in systolic heart failure patients in a
prospective, open-label study. Adv Ther 2015;32:108-19.
Table of Contents for the Digital Edition of ESC Congress 2016
ESC Congress 2016 - Cover1
ESC Congress 2016 - Cover2
ESC Congress 2016 - i
ESC Congress 2016 - ii
ESC Congress 2016 - Contents
ESC Congress 2016 - 2
ESC Congress 2016 - 3
ESC Congress 2016 - 4
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ESC Congress 2016 - 15
ESC Congress 2016 - 15A
ESC Congress 2016 - 15B
ESC Congress 2016 - 15C
ESC Congress 2016 - 15D
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ESC Congress 2016 - Cover3
ESC Congress 2016 - Cover4