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 ß-Blocker Ivabradine + ß-Blocker Heart rate Stroke volume Cardiac output Blood pressure 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. References 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. Closing 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 2013;6:403-10. 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 Cardiol 2015;116:1890-7. 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 Genet 2013;45:621-31. 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