Oral Ivabradine Research Articles

Evaluation of efficacy of oral ivabradine for attenuation of hemodynamic response to intubation in hypertensive surgical patients: Effect on rate pressure product as an index of myocardial oxygen demand

Abstract Background and Aims: An exaggerated hemodynamic response to endotracheal intubation is observed in hypertensive patients, and its attenuation proves challenging. The role of oral ivabradine, a unique heart rate-lowering drug with a favorable hemodynamic profile, is not yet studied. The aim of this study was to evaluate the effect of oral ivabradine on the attenuation of hemodynamic response to endotracheal intubation in hypertensive surgical patients assessed by rate pressure product (RPP), which is a very reliable indicator of myocardial oxygen demand. Material and Methods: Sixty medically controlled hypertensive surgical patients, aged 30–65 years, receiving general anesthesia were divided into two equal groups: Group I received a tablet of ivabradine 5 mg and group C received a placebo tablet 1 hour before induction. Heart rate (HR) and systolic, diastolic, and mean arterial blood pressure (SBP, DBP, and MAP) were recorded at baseline, preoperative, immediately after intubation, 1 min, 3 min, 5 min, and 10 min following intubation. RPP was calculated at the above time intervals. Data were analyzed using the unpaired t-test and the Chi-square test as required, with P < 0.05 considered significant. Results: The maximum value of RPP after intubation was significantly less in group I (11065.64 ± 606.56) as compared to group C (16774.64 ± 1242.87), P = 0.000. All hemodynamic variables, RPP, HR, SBP, DBP, and MAP, remained significantly less in group I than group C at all time intervals (P = 0.000). These parameters never increased above baseline after intubation in the ivabradine group, indicating effective attenuation of the intubation response. Conclusion: Premedication with oral ivabradine 5 mg is very effective in attenuating the hemodynamic response to intubation in hypertensive patients.

Attenuation of hemodynamic response to laryngoscopy and endotracheal intubation using oral ivabradine – Randomised controlled trial

Endotracheal intubation is one of the most common procedures, and anesthesiologists play an important role in patient care. During laryngoscopy and intubation, the patient can experience rapid and drastic hemodynamic changes that are potentially fatal. The purpose of this study is to know the efficacy of ivabradine in attenuating the hemodynamic response to laryngoscopy and endotracheal intubation. In this prospective randomised double-blinded study, fifty patients belonging to ASA 1 and 2 were randomised to group A - ivabradine 5mg (first dose on the evening before the day of surgery and the second dose one hour before intubation). Patients in group B received tablet MVT (placebo) (first dose on the evening before the day of surgery and the second dose one hour before intubation). Patients in group A showed attenuation of heart rate during laryngoscopy and intubation till 10minutes after intubation. Patients in group B showed a rise in blood pressure during laryngoscopy and intubation till 10 minutes after intubation. Patients in group A and group B showed no significant difference in hemodynamics when monitored intraoperatively. All patients recovered fully from anaesthesia and had no complications such as severe bradycardia. Ivabradine effectively attenuates the hemodynamic stress response without a fall in blood pressure and without severe bradycardia.

Oral Clonidine versus Ivabradine for Attenuating Stress Response in Functional Endoscopic Sinus Surgery: A Randomised Placebo-controlled Study

Introduction: Peri-anaesthetic haemodynamic alterations, such as hypertension and tachycardia, can cause increased bleeding during Functional Endoscopic Sinus Surgery (FESS), impairing the visibility of the surgical field and resulting in scarring, adhesions, and prolonged surgery time. Various strategies involving pharmacological techniques have been used to mitigate these unfavourable reflexes. Alpha-2 agonists, such as Clonidine, are currently being employed to attenuate sympathoadrenal stimulation caused by tracheal intubation and surgery. Ivabradine is a new drug that selectively lowers Heart Rate (HR) by inhibiting cardiac funny current channels. Aim: To compare the effects of premedication with oral Clonidine versus oral Ivabradine on attenuating haemodynamic stress response and improving the quality of the surgical field in FESS. Materials and Methods: The present randomised, placebocontrolled, double-blind study was conducted in the Department of Anaesthesiology and Intensive care at Rajendra Hospital, Government Medical College, Patiala, Punjab, India from April 2021 to December 2022 on 90 American Soceity of Anaesthelogists ( ASA) Physical status I and II adult patients (aged 18-60 years) undergoing FESS. Group A (n=30) received oral Ivabradine 5 mg, Group B (n=30) received oral Clonidine 0.2 mg, and Group C (n=30) received oral placebo tablets 2 hours before surgery. Haemodynamic parameters, including HR and Mean Arterial Pressure (MAP), quality of the intraoperative surgical field, postoperative sedation score, Visual Analogue Scale (VAS) score, time to analgesia request, blood loss, and adverse effects, were recorded. Descriptive statistics were used to calculate mean±Standard Deviation (SD) and percentage. Analysis of Variance (ANOVA), Tukey post-hoc test, Kruskal-wallis H test, and Pearson’s Chi-square were applied as appropriate. Results: The mean ages were 33.87±12.84, 35.03±12.93, and 40.9±14.46 years for Groups A, B, and C, respectively. The mean weights were 60.5±8.91, 57.83±5.66, and 57.9±5.42 kg, and the mean duration of surgery was 88.67±4.29, 88.8±4.29, and 88.03±3.93 minutes for Groups A, B, and C, respectively. There were no significant differences in terms of gender, ASA score, and type of surgery between the groups. Baseline HR and MAP were comparable among the groups. HR was significantly lower in both Groups A and B compared to Group C at all time intervals (p-value <0.001). Both drugs significantly attenuated tachycardia and hypertension in response to cardiovascular stress induced by laryngoscopy, endotracheal intubation, and extubation. However, Group B showed significantly better control of MAP throughout the intraoperative period and at extubation. The average category scale score, estimated blood loss, and postoperative VAS Score were all significantly lower in Group B than in Group A. Postoperative sedation scores were significantly higher in Group B, and the time to first rescue analgesic was longest in Group B (p<0.05). No significant side effects were observed. Conclusion: Both Clonidine and Ivabradine effectively attenuated the haemodynamic stress response. Clonidine provided better control of MAP, resulting in reduced bleeding, improved operative field visibility, and lower postoperative analgesic requirements compared to Ivabradine.

Comparative Study of Hemodynamic Response to Intubation with and without Oral Ivabradine in Patients Undergoing laparoscopic Surgery

Comparative Study of Hemodynamic Response to Intubation with and without Oral Ivabradine in Patients Undergoing laparoscopic Surgery

Effect of oral premedication with ivabradine on surgical field and intraoperative bleeding during functional endoscopic sinus surgeries: A prospective, randomized, and placebo-controlled study

Background: Ivabradine is an effective drug to prevent abnormal increase in heart rate (HR). Aims and Objectives: The aims of this study were to determine if a pre-operative oral dose of ivabradine (2.5 mg) reduces intraoperative bleeding during functional endoscopic sinus surgery (FESS) and improves visualization of operative field. Materials and Methods: A prospective, randomized, and placebo-controlled study was carried out in 30 patients of ASA grade I and II, aged between 18 and 60 years undergoing FESS surgeries. The patients were randomly allocated into two groups. Group I – received 2.5 mg of tablet ivabradine and Group P – received a placebo (vitamin tablet) 1 h before surgery. Blood loss and hemodynamic parameters (HR, systolic, diastolic, and mean blood pressure) were assessed perioperatively. Surgical field was graded by operating surgeon using Fromme – Boezaart score (FBS) at the end of procedure. Post-operative monitoring for any complications was also done. Results: Mean final blood loss in Group I was 165.73±43.48 mL and in Group P was 246.25±30.76 mL. There was a significant difference in mean final blood loss (mL) between two groups with P<0.001. In Group I – 13.33% had FBS 1 and 86.67% had FBS 2, whereas in Group P – 6.67% had FBS 2, 86.67% had FBS 3, and 6.67% had FBS 4. Thus, Group I had lower FBS scores than Group P and was statistically significant. Conclusion: Pre-operative oral ivabradine helps in reducing intraoperative bleeding in FESS surgery and provides good surgical field compared to placebo.

COVID 19 vaccine induced thrombotic thrombocytopenia, cerebral venous thrombosis and neurogenic stunned myocardium.

To the Editor, Vaccine-induced thrombotic thrombocytopenia (VITT) manifesting as cerebral venous thrombosis (CVT) is rare but life-threatening complication after COVID-19 vaccination.[1] Neurogenic stunned myocardium (NSM) is a phenomenon of cardiac abnormalities occurring due to sympathetic storm after acute neurological injury.[2] This case reporting is done after obtaining written informed consent. We describe rare manifestation of VITT, CVT, and NSM after COVID-19 vaccination and its successful management. A 19-year-old lady presented with altered sensorium for 2 days. Prior to her current visit, she had low-grade fever for 2 days and holocranial headache with vomiting for one week after COVID-19 vaccination with COVAXIN® (Bharat Biotech). On examination, she was drowsy, obeying simple commands on repeated asking, aphasic, with motor power of 3/5. Her pupils were equal and reactive. Respiratory and cardiovascular system examination was normal. Brain computed tomography showed left temporo-parietal CVT with raised intracranial pressure (ICP), midline shift to right and left transverse sinus thrombosis [Figure 1]. Laboratory tests revealed thrombocytopenia (platelet count 43,000/μL), elevated D-dimer (7457 ng/mL), and prolonged prothrombin time (18.8s). VITT associated CVT was diagnosed. In view of neurological status and imaging findings, she underwent emergency temporo-parieto-occipital decompressive craniectomy. She received four units of random donor platelet transfusion and three units of fresh frozen plasma before and during surgery. She was shifted to neuro-intensive care unit for elective ventilation and further management. VITT was managed with Fondaparinux and therapeutic plasma exchange (TPE). On 2nd postoperative day (POD), she developed persistent hypotension with tachycardia resistant to fluid therapy, with abnormal arterial blood gas (PaO2 = 40.9 mmHg, PaCO2 = 25.7 mmHg, pH = 7.48, SaO2 = 80.9%). Hence, norepinephrine was started, positive end expiratory pressure (PEEP) and fraction of inspired oxygen (FiO2) increased to 8 cm water and 0.7, respectively. Following this, her heart rate was 112/min, blood pressure was 112/80 mmHg, electrocardiogram showed sinus tachycardia and oxygen saturation was 90%. The FiO2 was gradually reduced with improvement in oxygenation. Transthoracic echocardiography (TTE) showed left ventricular global hypokinesia with ejection fraction of 34%. She was diagnosed with acute left ventricular failure from NSM. Dobutamine and furosemide infusion with oral ivabradine resulted in improvement and cardiovascular medications were tapered and stopped on 9th POD and trachea was extubated on 10th POD. After 24h observation, she was shifted to ward and subsequently discharged home with improved neurological status. Follow up TTE at discharge showed normal cardiac contractility.Figure 1: Contrast computed tomography of the brain showing large temporo-parietal hematoma due to cerebral venous thrombosis with midline shift, mass effect, and significant cerebral edema with loss of gray-white differentiationVITT is characterized as vaccine-induced immune syndrome of severe thrombosis, antibodies to platelet factor 4–polyanion complexes and thrombocytopenia.[3] VITT begins 5-10 days after vaccination and is diagnosed between 5 to 30 days.[4] It is associated with CVT, splanchnic vein thrombosis, deep venous and arterial thrombosis with thrombocytopenia, and elevated D-dimer. Treatment includes non-heparin anticoagulants such as indirect Xa inhibitors (fondaparinux, danaparoid), oral anticoagulants or thrombin inhibitors (argatroban, bivalirudin), and intravenous immunoglobulin or TPE. NSM is reported after stroke, traumatic brain injury, and subarachnoid hemorrhage but not after CVT. Catecholamine excess, systemic inflammation, and neuroendocrine derangements contribute to occurrence of NSM.[5] It is likely that the NSM in our patient was due to interplay of acute increase in ICP (neurogenic) from VITT-associated malignant CVT and systemic vaccine-induced complication-associated stress on the myocardium. Treatment is supportive to improve myocardial function and prevents cardiovascular complications including sudden death.[5] Ivabradine reduces heart rate and improves cardiac failure while dobutamine improves hemodynamic instability associated with NSM.[5,6] To conclude, VITT-associated CVT leading to NSC is rare and challenging to identify and manage. Management goals include reduction of acute intracranial hypertension, restoration of platelet function, anti-coagulation, and supporting cardiac function. Patient consent form Yes. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Comparing the effect of oral ivabradine versus oral propranolol premedication during controlled hypotensive anesthesia in functional endoscopic sinus surgery

ABSTRACT Background Reflex tachycardia that occurs during nitroglycerin-induced hypotensive anesthesia in functional endoscopic sinus surgery (FESS) increases both the risk of intraoperative bleeding and the duration of surgery. Our clinical trial aimed to compare the effect of oral ivabradine versus oral propranolol as a premedication before nitroglycerin-induced hypotensive anesthesia on the reduction of reflex tachycardia in FESS. Methods In this clinical, comparative, prospective, randomized, controlled, double-blinded study, 40 patients were divided into two equal groups (20 each); group P received oral propranolol (10 mg tablet) and group I received oral ivabradine (5 mg tablet) in the evening before the surgery and 1 hour before the induction of anesthesia. Results The reduction in heart rate (HR) was statistically significantly higher in group I than in group P. Conversely, the reduction in mean blood pressure (MAP) was statistically significantly higher in group P than in group I at baseline (pre-induction). However, after that, MAP reduction was statistically non-significant between both groups. Meanwhile, there was no statistically significant difference between both groups as regards duration of surgery, duration of deliberate hypotension, intraoperative NTG infusion doses, and the amount of bleeding. Conclusion Premedication with oral propranolol 10 mg or oral ivabradine 5 mg before FESS proved to be safe and effective in the reduction of reflex tachycardia that occurs during controlled nitroglycerin induced hypotensive anesthesia in FESS. However, ivabradine was more effective with higher safety profile than propranolol.

Treatment Strategy in Atrial Tachycardia Originating From the Atrial Appendage.

Background: Atrial appendage tachycardia (AAT) originating from the atrial appendage (AA) is extremely difficult to eliminate using radiofrequency catheter ablation (RFCA). The optimal management strategy for AAT refractory to RFCA remains unclear. Objective: This study aims to investigate the long-term result of ablative therapy and the optimal alternative management for AAT refractory to RFCA. Methods: A total of 51 patients with AAT originating from the AA undergoing RFCA were recruited. Video-assisted atrial appendectomy and oral ivabradine were performed on those with AATs refractory to RFCA, and this study aimed to evaluate their safety and long-term efficacy. Results: We included 51 patients (51/586, 8.7%) with AATs confirmed by activation mapping and contrast venography. Among them, there were 28 (54.9%) AATs originating from the distal AA. In total, 14 (27.4%) AATs were refractory to RFCA, including 13 originating from the distal AA and one arising from the proximal AA. Ten of 11 (90.9%) AATs originating from the distal AA were eliminated after an atrial appendectomy, and the other three AATs were suppressed using oral ivabradine. Origins from the distal AA refractory to RFCA and early age of AAT onset ≤26.5 years indicated the need for atrial appendectomy. No major complications occurred, and nine patients with tachycardia-induced cardiomyopathy fully recovered. Long-term success was achieved in 98.0% of patients with multiple treatment managements. Conclusion: AATs originating from the distal AA were more refractory to RFCA. RFCA was the cornerstone of AAT catheter ablation. Video-assisted thoracoscopic atrial appendectomy was an effective strategy for those origins at the distal AA and the age of AAT onset ≤26.5 years. Ivabradine represents a promising treatment for AAT temporarily in pediatric and young adult patients.

Consequence and Prevention of Haemodynamic Stress Response During Laryngoscopy and Endotracheal Intubation with Oral Ivabradine- A Multicentric Randomised Controlled Study

Introduction: Laryngoscopy and intubation cause lots of haemodynamic changes which adversely affects the patient during the perioperative period. Various methods have been applied to reduce stress response in high risk patients. Ivabradine is a unique cardiotonic drug which reduces the heart rate without compromising blood pressure, specially in debilitating and severely ill patients. Aim: To evaluate role of oral ivabradine in attenuating the haemodynamic stress response to laryngoscopy, intubation and extubation in patients undergoing surgical procedure under General Anaesthesia (GA) and to note the side effects and and its complications, if any. Materials and Methods: A randomised double blinded study was conducted in 200 American Society of Anaesthesiologists’ (ASA)-I and II patients undergoing various surgery under general anaesthesia. The patients were randomly divided into two groups: group A (Test group, n=100) received 5 mg oral ivabradine one hour before intubation, group B (Control group, n=100) received placebo. The pulse rate, Systolic Blood Pressure (SBP) and Diastolic Blood Pressure (DBP) and Mean Arterial Pressure (MAP) were recorded at intubation and 10 minutes postintubation along with at extubation and postintubation period till 10 minutes. Patients were monitored for haemodynamic changes as per the protocol. Statistics analysis was done using Statistical Package of Social Science (SPSS) software version 21.0. Results: Demographic findings were comparable in both groups. Heart rate (84.36±4.11 versus 114.19±12.4), SBP (120±10.5 versus 150±17.5), DBP (76.08±4.29 versus 113.2±10.6), MAP (91.3±6.7 versus 124.4±12.8) at 10 minutes postintubation decreased more in test group as compared to control group from baseline (p-value<0.005). Similarly, heart rate (84.13±2.06 versus 110.58±8.92), SBP (123.4±10.06 versus 150.8±13.1), DBP (84.08±2.02 versus 107±10.2), MAP (97.8±6.47 versus 122.06±9.7) at 10 minutes postintubation decreased significantly in test group as compared to control group from baseline (p-value<0.005). Conclusion: Oral ivabradine is a very useful cardiotonic drug which facilitates the fluctuation in heart rate during laryngoscopy and endotracheal intubation.

The Efficacy of Oral Ivabradine in Acute Phase in Non ST-segment Elevation Myocardial Infarction (NSTEMI) Post PCI: A Pilot Study

Background: An elevated heart rate is a major risk factor for cardiovascular mortality and morbidity. This study aims to evaluate the beneficial effect of heart rate reduction of oral ivabradine in patients presenting with non ST-segment elevation myocardial infarction (NSTEMI) during acute stage post percutaneous coronary intervention. Results: A total of 100 patients admitted to the emergency department, National Heart Institute, Cairo, Egypt, were randomized into two groups as follows: Group A: 50 patients with NSTEMI treated with ivabradine (5 mg twice daily) in addition to the conventional treatment; Group B: 50 patients with NSTEMI treated with the conventional treatment only. Demographic data, detailed history, clinical examination, chest pain onset, blood pressure, heart rate (HR), temperature and respiratory rate, electrocardiogram (ECG) as well as echocardiography and laboratory investigations were recorded. Patients were monitored for a period of 3e5 days (acute stage). There was a significant difference between both groups regarding reduction of heart rate on discharge in patients presenting with NSTEMI (P < 0.05). However, there was no significant differences in mortality, heart failure (HF), cardiogenic shock, arrhythmia and any mechanical complications in the acute stage. Conclusion: Ivabradine significantly reduced heart rate in patients with NSTEMI without affecting blood pressure or hemodynamics; however, this did not show a significant impact on major adverse cardiac events (MACE) during shortterm follow up in the Coronary Care Unit (CCU) (Clinicaltrials.gov NCT04285736).

Abstract 12849: Invasive Assessment of Hemodynamic Effect of Ivabradine in Post ST Segment Elevation Myocardial Infarction Associated Sinus Tachycardia

Introduction: Post MI tachycardia is associated with increase in cardiac morbidity and mortality. We aimed to assess efficacy and safety of ivabradine to control heart rate in post MI tachycardia patients in whom beta-blockers were intolerant. Hypothesis: We hypothesized that ivabradine in post MI tachycardia patients effectively control heart rate without deteriorating effects on hemodynamics. Methods: STEMI patients with sinus tachycardia (heart rate &gt;120/min) who had intolerance to beta blocker were enrolled. Important exclusions were cardiogenic shock, second /third-degree atrioventricular block, Killip class III/ IV. Patient’s invasive hemodynamic parameters such as MAP (Mean Arterial Pressure), iSV (indexed Stroke Volume), CVP (Central Venous Pressure), cardiac output and cardiac index were measured with help of Edwards LifeSciences Flotrac monitor. Patients received ivabradine till heart rate control (&lt;100/min.) was achieved. The primary objectives were to study ivabradine efficacy to achieve target heart rate, and its effects on hemodynamic parameters and secondary objectives were to assess any adverse events. Results: Mean age was 52.7 ± 9.8 years and 29 (81%) were male. At enrolment, mean heart rate, MAP, iSV and CVP was 128.92±3.3bpm, 87.31±10.46mmHg, 28.19±7.85ml/m 2 , 6.35±2.61 mmHg respectively. At target heart rate ≤1oo/min (mean 96.57±5.29bpm), MAP, iSV and CVP were 82.71±13.70 mmHg (P=0.559), 1.11±6.33ml/m 2 (P=0.087) and 7.7±2.54 mmHg (P=0.122) showed no significant changes. However, cardiac output and cardiac index dropped to 5.22± 1.00 L/min (P=0.005) and 2.96±0.60 L/min/m 2 (P=0.005) but within physiological limits. None of the patient reported hypotension, arrhythmia, heart failure or in-hospital mortality. Conclusions: Invasive hemodynamic evaluation showed oral ivabradine is effective and safe alternative to control heart rate in uncomplicated post MI sinus tachycardia patients who had intolerance to beta-blockers.

Ivabradine Versus Amiodarone in the Management of Postoperative Junctional Ectopic Tachycardia: A Randomized, Open-Label, Noninferiority Study.

This study sought to compare the efficacy of ivabradine and amiodarone in the management of postoperative junctional ectopic tachycardia (JET) after cardiac surgery in children. JET is a serious arrhythmia occurring in children after cardiac surgery and requires aggressive management. Amiodarone has been conventionally used in its treatment. Recent studies have reported the utility of ivabradine in this regard. In this open-label randomized controlled trial, 94 children (age≤18 years) who developed postoperative JETwere allocated to receive either amiodarone or ivabradine. The primary endpoint was restoration of normal sinus rhythm. Sinus rhythm was achieved in 43 out of the 46 patients (93.5%) in the amiodarone group and 46 out of the 48 patients (95.8%) in the ivabradine group (mean difference of treatment effect: 2.3%; 95% confidence interval:-6.7% to 11.5%). The median (interquartile range) time taken to achieve sinus rhythm conversion was similar in both the groups: 21.5 (17-30.2) hours versus 22 (13.4-38.5) hours (p=0.36)]. The time taken to rate control of JET was significantly less in the amiodarone group: median 7.0 (5.5-9.5) hours versus 8.0 (5.8-10.8) hours (p=0.02)]. No drug-related adverse events were observed in the ivabradine group. Oral ivabradine is not inferior to intravenous amiodarone in converting postoperative JET to sinus rhythm. There was no difference in time taken to sinus rhythm conversion between the groups, although the rate control was earlier in patients who received amiodarone. Monotherapy with ivabradine may be considered as an alternative toamiodarone in the management of postoperative JET. (Comparison of Two Drugs, Ivabradine and Amiodarone, in theManagement of Junctional Ectopic Tachycardia, an Abnormality in Cardiac Rhythm in Patients Under 18 years Who Undergo Cardiac Surgery: CTRI/2018/08/015182).

Effectiveness of point-of-care oral ivabradine for cardiac computed tomography

BackgroundCoronary CT angiography (CCTA) is increasing seen as a first line investigation in patients with suspected coronary artery disease. Heart-rate control improves the image quality and diagnostic accuracy of CCTA. Typically, beta-blockers are administered to induce sinus bradycardia. Sinus bradycardia may also be induced by ivabradine. We hypothesized that in a real-world population ivabradine would be an effective alternative to metoprolol at heart rate lowering for CCTA. MethodsThis was a retrospective analysis of consecutive patients who were exposed to an ivabradine-based (IB) versus a metoprolol-only (MO) protocol to achieve a target heart rate </ = 65bpm. Hemodynamic responses to both strategies were compared along with differences in cost and the time expired from medication administration to CCTA. Results5955 consecutive patients were included in the analysis: 3211 were imaged during an era of a metoprolol only strategy (MO) and 2744 CCTA following an ivabradine based (IB) strategy. 2676 patients had heart rates >65 and received heart-rate lowering medication: 1958 patients had MO, and 718 received IB protocol. Target heart rate of </ = 65bpm was achieved in 77% of MO and 89% of IB patients (p < 0.01). The time from initial medication administration to CCTA was longer in the IB versus MO patients (77 versus 48 min, p < 0.01). ConclusionsIntroduction of a novel single dose ivabradine-based protocol to control heart rate for CCTA was more successful in achieving target heart rate than a metoprolol-only strategy. The use of ivabradine however incurred a 1.6-fold increase in the time delay from medication administration and imaging compared to a metoprolol only protocol.

Efficacy of Oral Ivabradine in Patients Presenting With NSTEMI

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Comparison of Effects of Oral Ivabradine and Oral Clonidine as Premedicants on Intraocular Pressure Changes Following Intubation with Succinylcholine

Comparison of Effects of Oral Ivabradine and Oral Clonidine as Premedicants on Intraocular Pressure Changes Following Intubation with Succinylcholine

New therapeutic option for junctional ectopic tachycardia in infants following congenital heart surgery: ivabradine, a case report

Junctional ectopic tachycardia (JET) is the most common tachyarrhythmia that appears mostly during the immediate postoperative period of congenital heart surgery. Patients who develop JET have increased mortality and morbidity. Despite the availability of different antiarrhythmic treatments, management of JET is still challenging. We report a case of reversing of malignant JET following congenital heart surgery with the use of oral Ivabradine, after the failure of all the others treatment options of JET. Ivabradine is a drug used in adult practice to lower heart rate in heart failure and angina. Our case report may provide hope that Ivabradine may be a new therapeutic option for JET in infants following congenital heart surgery.

Ivabradine as an Adjunct for Refractory Junctional Ectopic Tachycardia Following Pediatric Cardiac Surgery: A Preliminary Study.

Junctional ectopic tachycardia (JET) is a relatively common narrow complex rhythm typically characterized by atrioventricular dissociation or retrograde atrial conduction in a 1:1 pattern. Junctional ectopic tachycardia can be a life-threatening disorder, causing severe hemodynamic compromise and increased morbidity and mortality. The treatment of refractory JET can be very difficult, even with multimodal therapeutic interventions. The purpose of this study was to assess the role of ivabradine in cases of JET refractory to amiodarone and esmolol. A total of 480 congenital heart surgeries were carried out at our center in 2017. Twenty (4.16%) patients had postoperative JET. Among these, five infants, aged 7 to 12 months (median: 8 months), had refractory JET. These patients (three tetralogy of Fallot, one ventricular septal defect, one complete atrioventricular septal defect) were treated with oral ivabradine in the dose range of 0.1 to 0.2 mg/kg/12 h as an adjunct to amiodarone. All five patients achieved rate reduction and eventual conversion to sinus rhythm. Mean duration to achieve heart rate of <140 bpm after initiation of ivabradine therapy was 16.8 hours (±7.2 hours), while mean duration to achieve sinus rhythm was 31.6 hours (±13.6 hours). No patient had any recurrence of JET. No patient exhibited any hemodynamic derangement nor side effects attributable to oral ivabradine. Oral ivabradine has the potential to be used as an adjunct to amiodarone in the treatment of JET in infants after surgery for congenital heart disease.

Clinical and Electrophysiological Correlates of Incessant Ivabradine-Sensitive Atrial Tachycardia

Incessant focal atrial tachycardia (FAT), if untreated, can lead to ventricular dysfunction and heart failure (tachycardia-induced cardiomyopathy). Drug therapy of FAT is often difficult and ineffective. The efficacy of ivabradine has not been systematically evaluated in the treatment of FAT. The study group consisted of patients with incessant FAT (lasting >24 hours) and structurally normal hearts. Patients with ventricular dysfunction as a consequence of FAT were not excluded. All antiarrhythmic drugs were discontinued at least 5 half-lives before the initiation of ivabradine. Oral ivabradine (adults, 10 mg twice 12 hours apart; pediatric patients: 0.28 mg/kg in 2 divided doses) was initiated in the intensive care unit under continuous electrocardiographic monitoring. A positive response was defined as the termination of tachycardia with the restoration of sinus rhythm or suppression of the tachycardia to <100 beats per minute without termination within 12 hours of initiating ivabradine. Twenty-eight patients (mean age, 34.6±21.5 years; women, 60.7%) were included in the study. The most common symptom was palpitation (85.7%) followed by shortness of breath (25%). The mean atrial rate during tachycardia was 170±21 beats per minute, and the mean left ventricular ejection fraction was 54.7±14.3%. Overall, 18 (64.3%) patients responded within 6 hours of the first dose of ivabradine. Thirteen of 18 ivabradine responders subsequently underwent successful catheter ablation. FAT originating in the atrial appendages was a predictor of ivabradine response compared with those arising from other atrial sites (P=0.046). Ivabradine-sensitive atrial tachycardia constitutes 64% of incessant FAT in patients without structural heart disease. Incessant FAT originating in the atrial appendages is more likely to respond to ivabradine than that arising from other atrial sites. Our findings implicate the funny current in the pathogenesis of FAT.

Attenuation of Hemodynamic Response to Laryngoscopy and Endotracheal Intubation by using Oral Ivabradine

Attenuation of Hemodynamic Response to Laryngoscopy and Endotracheal Intubation by using Oral Ivabradine

Study of Attenuation of Hemodynamic Response to Laryngoscopy and Endotracheal Intubation using Intra-oral Ivabradine.

Context:Endotracheal intubation is one of the most commonly performed procedures, where rapid and dramatic hemodynamic changes which adversely affect the patient may occur during the perioperative period. Various strategies have been applied to attenuate these responses in high-risk individuals. Ivabradine is a very unique cardiotonic drug in the medical literature which reduces the heart rate without jeopardizing hemodynamics in unhealthy, compromised patients.Aims and Objective:The aim of this study is to evaluate the effect of oral ivabradine on the hemodynamics during laryngoscopy and endotracheal intubation in patients undergoing surgical procedure under general anesthesia and to note the side effects and complications.Settings and Design:This was a prospective, randomized, and double-blind controlled study.Subjects and Methods:A total of 50 American Society of Anesthesiologists physical status I patients between 20 and 50 years age comparable in demographic variables of either sex, undergoing surgery under general anesthesia were randomized into two groups, namely, Group T and Group C of 25 each. Group T (test group) received tablet ivabradine 5 mg 1 h before intubation. Group C (control group) received placebo 1 h before intubation. The pulse rate, systolic and diastolic blood pressures, and mean arterial pressure were recorded for around 10 min and surgery was not allowed to commence. These hemodynamic variables were measured preoperatively, at intubation, after 1 min, 5 min, 8 min and 10 min postintubation.Statistical Analysis Used:The Chi-square test and ANOVA test using INDOSTAT software for hemodynamics were used in this study.Results:There was an increase in all parameters in the control group during and postintubation and was undisturbed in the test group as compared to base line. The increase was constant up to 3 min and got settled within 5 min in the control group.Conclusion:Ivabradine had better patient compliance in terms of blunting laryngoscopic pressor.