Ivabradine for the treatment of stable angina pectoris in octogenarians

Effectiveness and Impact on Adherence of a New Fixed-Dose Combination of Ivabradine and Metoprolol in a Wide Range of Stable Angina Patients in Real-Life Practice

INTRODUCTION

The antianginal effectiveness of ivabradine administration in addition to beta-blockers has been shown in patients with stable angina. The first fixed-dose combination (FDC) of ivabradine and metoprolol is now available and its evaluation in various stable angina patient populations relevant to clinical practice would be useful.

METHODS

In this 4-month, prospective, multicenter, observational study, the effectiveness and tolerability of the metoprolol/ivabradine FDC was assessed in patient subgroups specified according to age, coronary artery disease (CAD) duration, Canadian Cardiovascular Society (CCS) class, co-morbidities, and previous myocardial infarction (MI) or revascularization. Heart rate (HR), angina attack frequency, short-acting nitrate (SAN) consumption, functional status, and medication adherence were documented at baseline and after 4 months of follow-up.

RESULTS

A total of 747 stable angina patients were included and divided into subgroups. At 4 months, a significant decrease in HR, angina attack frequency, and SAN consumption per week was consistently observed across all patient subgroups. The proportion of CCS class I patients increased significantly from baseline to month 4. In all patient subgroups, at 4 months, a significant increase was observed in the proportion of patients with self-reported complete adherence. Complete adherence at the final visit was found to decrease with an increasing number of medications. Physicians evaluated the effectiveness and tolerability of the FDC as 'very good' and 'good' for more than 96% of patients in all analyzed patient subgroups.

CONCLUSIONS

Treatment with metoprolol/ivabradine FDC significantly improved angina symptoms and adherence, with an excellent tolerability profile, in stable angina patient subgroups relevant to real-life clinical practice, regardless of age, CAD duration, CCS class, comorbidities, previous MI, or history of revascularization.

TRIAL REGISTRATION

ISRCTN51906157.

FUNDING

This study was sponsored by Servier Deutschland GmbH. Editorial assistance and the Rapid Service Fee were funded by Servier, France. Plain language summary available for this article.

Advances in small-molecule therapy for managing angina pectoris in the elderly

Introduction: As our population ages, the prevalence of angina is growing, leading to increased morbidity and decreased quality of life. The management of angina in the elderly is challenging due to drug intolerance and/or drug resistance as well as frailty. Over the past decades, many new therapeutic small molecules have been investigated for the management of angina. Although none of these studies have specifically focused on the therapies for the elderly, they offer promising new avenues for the treatment of angina in the elderly. Areas covered: Herein, the authors provide a review of the recently published literature on the use of small-molecule therapies for angina management in the elderly and provide a brief overview of these therapies. Expert opinion: A variety of therapeutic classes of existing and newer small molecules are emerging for the management of angina in the elderly. An individualized approach to the management of angina in this growing population is critical for good outcomes. Many small molecules are in their initial stages of clinical use, and further research should be conducted on their utility, especially in the elderly.

Role of ivabradine in management of stable angina in patients with different clinical profiles

In chronic stable angina, elevated heart rate contributes to the development of symptoms and signs of myocardial ischaemia by increasing myocardial oxygen demand and reducing diastolic perfusion time. Accordingly, heart rate reduction is a well-known strategy for improving both symptoms of myocardial ischaemia and quality of life (QOL). The heart rate-reducing agent ivabradine, a direct and selective inhibitor of the I_f current, decreases myocardial oxygen consumption while increasing diastolic time, without affecting myocardial contractility or coronary vasomotor tone. Ivabradine is indicated for treatment of stable angina and chronic heart failure (HF). This review examines available evidence regarding the efficacy and safety of ivabradine in stable angina, when used as monotherapy or in combination with beta-blockers, in particular angina subgroups and in patients with stable angina with left ventricular systolic dysfunction (LVSD) or HF. Trials involving more than 45 000 patients receiving treatment with ivabradine have shown that this agent has antianginal and anti-ischaemic effects, regardless of age, sex, severity of angina, revascularisation status or comorbidities. This heart rate-lowering agent might also improve prognosis, reduce hospitalisation rates and improve QOL in angina patients with chronic HF and LVSD.

Ivabradine in Patients with Stable Coronary Artery Disease: A Rationale for Use in Addition to and Beyond Percutaneous Coronary Intervention

Heart rate is an established prognostic marker for longevity and is an important contributor in the pathophysiology of various cardiovascular diseases, including ischemic heart disease and heart failure. Most ischemic episodes are triggered by an increase in heart rate, which causes an imbalance between myocardial oxygen delivery and consumption. In addition, increased heart rate is a modifiable risk factor for chronic heart failure. Ivabradine, an inhibitor of I_f ion channels, is an approved second-line anti-ischemic drug for the treatment of angina. Ivabradine has been shown to decrease the risk of hospitalization in patients with chronic heart failure who were previously treated with β-blockers, renin-angiotensin system blockers or mineralocorticoid receptor antagonists. This review describes the rationale for the pathophysiological and clinical use of ivabradine as an anti-ischemic agent in patients with stable coronary disease and highlights its benefits and drawbacks compared with other first- and second-line anti-anginal drugs. The review also highlights the role of ivabradine as a treatment for patients with high-risk coronary artery disease in whom first-line anti-anginal drugs are insufficient or inadequate and percutaneous coronary intervention is contraindicated or revascularization is incomplete or unsuitable.

Selective and specific inhibition of If with ivabradine for the treatment of coronary artery disease or heart failure

Heart rate is an important contributor in the pathophysiology of both coronary artery disease (CAD) and heart failure (HF). Ivabradine is an anti-anginal and anti-ischaemic agent, which selectively and specifically inhibits the I_f current in the sino-atrial node and provides pure heart rate reduction without altering other cardiac parameters, including conduction, and without directly affecting other haemodynamic parameters. It is approved for the treatment of CAD and HF. This article summarises the pharmacological properties, pharmacokinetics, clinical efficacy and tolerability of ivabradine in the treatment of CAD and HF, and presents evidence demonstrating that the pharmacological and clinical properties and clinical efficacy of ivabradine make it an important therapeutic choice for patients with stable CAD or HF. The positive effect of ivabradine on angina pectoris symptoms and its ability to reduce myocardial ischemia make it an important agent in the management of patients with stable CAD or chronic HF. Further studies are underway to add to the already robust evidence of ivabradine for the prevention of cardiovascular events in patients with CAD but without clinical HF. The SIGNIFY (Study assessInG the morbidity–mortality beNefits of the I_f inhibitor ivabradine in patients with coronarY artery disease) trial includes patients with stable CAD and an LVEF above 40 %, with no clinical sign of HF, and is investigating the long-term effects (over a period of 48 months) of ivabradine in a large study population. So far, this study has included more than 19,000 patients from 51 countries.

Ivabradine: potential clinical applications in critically ill patients

It has been extensively demonstrated that an elevated heart rate is a modifiable, independent risk factor for cardiovascular events. A high heart rate increases myocardial oxygen consumption and reduces diastolic perfusion time. It can also increase ventricular diastolic pressures and induce ventricular arrhythmias. Critical care patients are prone to develop a stress induced cardiac impairment and consequently an increase in sympathetic tone. This in turn increases heart rate. In this setting, however, heart rate lowering might be difficult because the effects of inotropic drugs could be hindered by heart rate reducing drugs like beta-blockers. Ivabradine is a new selective antagonist of funny channels. It lowers heart rate, reducing the diastolic depolarization slope. Moreover, ivabradine is not active on sympathetic pathways, thus avoiding any interference with inotropic amines. We reviewed the literature available regarding heart rate control in critical care patients, focusing our interest on the use of ivabradine to assess the potential benefits of the drug in this particular setting.

Ivabradine: an intelligent drug for the treatment of ischemic heart disease

Heart rate (HR) is a precisely regulated variable, which plays a critical role in health and disease. Elevated resting HR is a significant predictor of all-cause and cardiovascular mortality in the general population and patients with cardiovascular disease (CVD). β-blocking drugs exert negative effects on regional myocardial blood flow and function when HR reduction is eliminated by atrial pacing; calcium channel antagonists (CCAs) functionally antagonize coronary vasoconstriction mediated through α-adreno-receptors and are thus devoid of this undesired effect, but the compounds are nevertheless negative inotropes. From these observations derives the necessity to find alternative, more selective drugs to reduce HR through inhibition of specific electrical current (I(f)). Ivabradine (IVA) is a novel specific HR-lowering agent that acts in sinus atrial node (SAN) cells by selectively inhibiting the pacemaker I(f) current in a dose-dependent manner by slowing the diastolic depolarization slope of SAN cells, and by reducing HR at rest during exercise in humans. Coronary artery diseases (CAD) represent the most common cause of death in middle-aged and older adults in European Countries. Most ischemic episodes are triggered by an increase in HR, that induces an imbalance between myocardial oxygen delivery and consumption. IVA, a selective and specific inhibitor of the I(f) current which reduced HR without adverse hemodynamic effects, has clearly and unequivocally demonstrated its efficacy in the treatment of chronic stable angina pectoris (CSAP) and myocardial ischemia with optimal tolerability profile due to selective interaction with I(f) channels. The aim of this review is to point out the usefulness of IVA in the treatment of ischemic heart disease.

The new oral adenosine A1 receptor agonist capadenoson in male patients with stable angina

BACKGROUND

Anti-ischaemic effect of A1 adenosine receptor agonists was shown in animal and preclinical studies. The present proof-of-concept study aimed at evaluation of the efficacy and safety of a new adenosine A1 receptor agonist capadenoson in patients with stable angina.

METHODS

This was a randomized, double-blind, placebo-controlled, single dose-escalating, multicenter trial comparing the effect of capadenoson at 1, 2.5, 5, 10, and 20 mg versus placebo. For each dose step patients were randomized to receive single doses of either capadenoson or matching placebo in a 5:1 ratio. The primary efficacy variable was the absolute difference in heart rate (HR) at maximum comparable level of workload between baseline and post dose exercise tolerance test at maximum concentration of capadenoson. Capadenoson effect on total exercise time and time to 1-mm ST-segment depression were also measured.

RESULTS

Sixty-two male patients with stable angina were enrolled in the study. There was a consistent trend for HR reduction at comparable maximum work load in active treatment groups, with significant differences against placebo for 10 and 20 mg (HR reduction by 12.2 and 6.8 beats per min, p = 0.0002 and p = 0.032, respectively). A statistically significant trend (p = 0.0003) for a reduction in HR with increasing doses of capadenoson was shown. Increases in total exercise time and time to 1-mm ST-segment depression were also observed.

CONCLUSIONS

In patients with stable angina capadenoson lowers exercise HR at comparable maximum workload, which is associated with improved total exercise time and prolongation of time to ischaemia.

Ivabradine in combination with beta-blocker improves symptoms and quality of life in patients with stable angina pectoris: results from the ADDITIONS study

AIM

Several clinical trials have demonstrated the antianginal and anti-ischemic efficacy of ivabradine in combination with beta-blocker in patients with stable angina pectoris. The ADDITIONS (PrActical Daily efficacy anD safety of Procoralan(®) In combinaTION with betablockerS) study evaluated the efficacy, safety, and tolerability of ivabradine added to beta-blocker, and its effect on angina symptoms and quality of life in routine clinical practice.

METHODS

This non-interventional, multicenter, prospective study included 2,330 patients with stable angina pectoris treated with a flexible dose of ivabradine twice daily in addition to beta-blocker for 4 months. The parameters recorded included heart rate, number of angina attacks, nitrate consumption, tolerance, and quality of life.

RESULTS

After 4 months ivabradine (mean dose 12.37 ± 2.95 mg/day) reduced heart rate by 19.4 ± 11.4 to 65.6 ± 8.2 bpm (p < 0.0001). The number of angina attacks was reduced by 1.4 ± 1.9 per week (p < 0.0001), and nitrate consumption by 1.9 ± 2.9 U per week (p < 0.0001). At baseline (i.e., on beta-blocker), half of the patients (51%) were classified as Canadian Cardiovascular Society (CCS) grade II; 29% were CCS grade I. After 4 months' treatment with ivabradine, most of the patients were CCS grade I (68%). The EQ-5D index improved by 0.17 ± 0.23 (p < 0.0001). The overall efficacy of ivabradine was considered by the physicians as "very good" (61%) or "good" (36%) in most patients. Suspected adverse drug reactions were documented in 14 patients; none were severe.

CONCLUSION

In daily clinical practice, combining ivabradine with beta-blocker not only reduces heart rate, number of angina attacks, and nitrate consumption, but also improves the quality of life in patients with stable angina pectoris.

[New agents for the therapy of angina pectoris]

There is a renaissance of medical treatment of chronic angina pectoris despite of advances in interventional therapy. New drugs include nicorandil, ivabradine and ranolazine. Nicorandil dilates venous and arterial vessels via relaxation of smooth muscle cells. Since the drug has only recently been approved, the German experience is limited. Ivabradine exerts an anti-anginous effect by selective action on the sinus node with reduction of heart rate. Multiple studies have demonstrated its anti-anginal efficacy, which has also been shown if it was used as an additional therapy to classic anti-anginal treatment. Its use is reasonable as a substitute for beta-blockers or as an "add-on therapy" combined with beta-blockers, if the target heart rate for treatment of angina pectoris has not been reached. Ranolazine delays the late sodium current into the myocytes. Thereby, it improves the diastolic ventricular function and the microcirculation of the myocardium. Several large studies confirmed the anti-anginal efficacy of the drug. Currently it is used if angina pectoris still occurs under a combined treatment with different classic anti-anginal drugs.

Reducing elevated heart rate in patients with multiple organ dysfunction syndrome by the I (f) (funny channel current) inhibitor ivabradine : MODI (f)Y trial

BACKGROUND

Heart rate (HR) is of relevant prognostic value not only in the general population and patients with cardiovascular disease, but also in critically ill patients with multiple organ dysfunction syndrome (MODS). An elevated HR in MODS patients is associated with a worse prognosis. Beta-blocker (BB) administration has been shown to reduce mortality in MODS. In most cases, negative inotropic effects prevent administration of BBs in MODS patients. In this trial we investigate, whether the "funny current" (I (f)) channel inhibitor ivabradine is able and apt to reduce pathologically elevated HR in MODS patients. We hypothesize that critically ill patients could derive particular benefit from the specific HR-lowering agent ivabradine.

METHODS

MODI (f)Y is a prospective, single centre, open label, randomized, controlled two arms, phase II-trial to evaluate the potential of ivabradine to reduce an elevated HR in MODS patients. The primary end point is the proportion of patients with a reduction of HR by at least 10 beats per minute (bpm) within 4 days. This trial will randomize 70 patients (men and women, aged ≥18 years) with newly diagnosed MODS, with an elevated HR (sinus rhythm with HR ≥90 bpm) and contraindications to BB therapy. Treatment period will last for 4 days. All patients will be followed for 6 months.

RESULTS

The first patient was randomized on May 21, 2010.

CONCLUSIONS

The MODI (f)Y trial is the first application of ivabradine as a pure heart rate reducing agent in MODS patients.