BPharm. MSc. clinical monitor at Laval University faculties of pharmacy and medecine. CHU de Québec-université Laval Lac Beauport, Quebec, Canada
Background: Up to 25% of patients undergoing hemodialysis have heart failure with reduced ejection fraction (HFrEF). Heart failure management in this population is particularly challenging, as impaired renal function and intradialytic hypotension often limit the use and up-titration of guideline-directed medical therapies. Therefore, beta blockers are frequently underutilized, despite elevated resting heart rate (HR) being a well-established predictor of adverse cardiovascular outcomes in HFrEF. Ivabradine, a selective sinus node inhibitor, has been shown in the SHIFT trial to reduce mortality and hospitalizations in patients with HFrEF through heart rate reduction. Ivabradine has minimal impact on blood pressure, which could prove especially useful in patients undergoing hemodialysis. However, patients with end-stage kidney disease (ESKD) on dialysis were excluded from prior trials. This study aimed to assess the safety and efficacy of ivabradine in this understudied population.
METHODS AND RESULTS: In this single-center, prospective, descriptive cohort study, we enrolled patients undergoing hemodialysis with stable HFrEF (left ventricular ejection fraction ≤ 35%), New York Heart Association functional class II-III symptoms, sinus rhythm, and a resting HR ≥ 77 bpm. Ivabradine was titrated to achieve a target heart rate of 50-60 bpm or to a maximum dose of 7.5 mg twice daily. The primary endpoint was change in resting HR after one year, serving as a surrogate for treatment efficacy and foreseeable cardiovascular risk reduction through comparison with the SHIFT cohort. The median resting HR decreased from 79 bpm prior to the initiation of ivabradine to 67 bpm after one year of treatment – mirroring the reduction in mean HR from 80 bpm to 67 bpm observed in the SHIFT trial. The mean achieved dose of ivabradine was 6.8 mg twice daily, closely aligning with the SHIFT trial (6.5 mg twice daily). No episodes of hypotension or serious adverse drug reactions were observed. New-onset atrial fibrillation led to drug discontinuation in a single patient.
Conclusion: Ivabradine appears to be a safe and effective adjunct therapy for HR reduction in patients with HFrEF and ESKD undergoing hemodialysis. Given its minimal impact on blood pressure and favorable tolerability profile, ivabradine may serve as a valuable option to improve cardiovascular outcomes in this high-risk population.
