Department of Clinical Cardiology, Heart Failure Clinic, Ospedale San Raffaele, Milano, Italy.
J Cardiovasc Med (Hagerstown). 2018 Jul;19(7):351-356. doi: 10.2459/JCM.0000000000000661.
: Ivabradine is a selective and specific inhibitor of If current. With its pure negative chronotropic action, it is recommended by European Society of Cardiology and American College of Cardiology/American Heart Association guidelines in symptomatic heart failure patients (NYHA ≥ 2) with ejection fraction 35% or less, sinus rhythm and heart rate (HR) at least 70 bpm, despite maximally titrated β-blocker therapy. Data supporting this indication mainly derive from the SHIFT study, in which ivabradine reduced the combined endpoint of mortality and hospitalization, despite the fact that only 26% of patients enrolled were on optimal β-blocker doses. The aim of the present analysis is to establish the real-life eligibility for ivabradine in a population of patients with systolic heart failure, regularly attending a single heart failure clinic and treated according to guideline-directed medical therapy (GDMT). The clinical cards of 308 patients with heart failure with reduced ejection fraction (HFrEF) through a 68-month period of observation were retrospectively analyzed. GDMT, including β-blocker up-titration to maximal tolerated dose, was implemented during consecutive visits at variable intervals. Demographic, clinical and echocardiographic data were collected at each visit, together with 12-leads ECG and N-terminal pro-B-type natriuretic peptide levels. Out of 308 analyzed HFrEF patients, 220 (71%) were on effective β-blocker therapy, up-titrated to effective/maximal tolerated dose (55 ± 28% of maximal dose) (HR 67 ± 10 bpm). Among the remaining 88 patients, 10 (3.2%) were on maximally tolerated β blocker and ivabradine; 21 patients (6.8%), despite being on maximal tolerated β-blocker dose, had still HR ≥70 bpm, ejection fraction 35% or less and were symptomatic NYHA ≥2, being therefore eligible for ivabradine treatment. The remaining 57 (18%) patients were not on β blocker due to either intolerance or major contraindications. Among them, 13 (4%) were taking ivabradine alone. Of the final 44 (14%) patients, 27 (9%) showed an inadequate HR control (74 ± 6 bpm). Of these, only eight (3%) patients resulted to be eligible for ivabradine introduction according to HR and ejection fraction parameters. Overall ivabradine was indicated in 52 patients (16.8%) out of 308 enrolled.In conclusion, in a carefully managed population of patients with moderate and stable HFrEF, in which optimal GDMT is properly attained, indication to ivabradine treatment is around 17%.
伊伐布雷定是一种选择性和特异性 If 电流抑制剂。由于其纯负性变时作用，在射血分数 35%或更低、窦性节律和心率（HR）至少 70 bpm 的有症状心力衰竭患者（NYHA≥2）中，欧洲心脏病学会和美国心脏病学会/美国心脏协会指南推荐使用伊伐布雷定。支持这一适应证的数据主要来源于 SHIFT 研究，该研究表明，尽管只有 26%的入组患者接受了最佳β受体阻滞剂剂量，但伊伐布雷定降低了死亡率和住院率的联合终点。本分析的目的是在一个定期接受单一心力衰竭诊所治疗并根据指南指导的药物治疗（GDMT）的收缩性心力衰竭患者人群中确定伊伐布雷定的真实适应证。通过对 308 例射血分数降低的心力衰竭（HFrEF）患者的临床资料进行回顾性分析，观察时间为 68 个月。在连续就诊期间，以可变间隔的方式实施 GDMT，包括β受体阻滞剂滴定至最大耐受剂量。在每次就诊时收集人口统计学、临床和超声心动图数据，以及 12 导联心电图和 N 末端 B 型利钠肽前体水平。在分析的 308 例 HFrEF 患者中，220 例（71%）接受了有效的β受体阻滞剂治疗，滴定至有效/最大耐受剂量（最大剂量的 55±28%）（HR 67±10 bpm）。在其余 88 例患者中，10 例（3.2%）接受了最大耐受剂量的β受体阻滞剂和伊伐布雷定；21 例（6.8%）尽管接受了最大耐受剂量的β受体阻滞剂，但 HR≥70 bpm，射血分数 35%或更低，且有症状 NYHA≥2，因此有资格接受伊伐布雷定治疗。其余 57 例（18%）患者因不耐受或主要禁忌证而未接受β受体阻滞剂治疗。其中，13 例（4%）单独服用伊伐布雷定。在最终的 44 例（14%）患者中，27 例（9%）HR 控制不理想（74±6 bpm）。其中，只有 8 例（3%）患者根据 HR 和射血分数参数被认为有资格使用伊伐布雷定。总的来说，在 308 例入组患者中，有 52 例（16.8%）需要使用伊伐布雷定。总之，在中等程度且稳定的 HFrEF 患者中，经过仔细管理并接受最佳 GDMT 治疗后，伊伐布雷定治疗的适应证约为 17%。
