1 ivabradine: is there a cardiovascular benefit to pure heart rate reduction? catheterization...
TRANSCRIPT
1
Ivabradine: Ivabradine: Is there a cardiovascular benefit to Is there a cardiovascular benefit to pure heart rate reduction?pure heart rate reduction?
Catheterization Conference
October 27, 2011
Anit Mankad, MD
3
Overview
Beta BlockersActivity, impact, intolerance
Adrenergic (sympathetic) activityIf current and “Funny” Channels
IvabradineEarly trials BEAUTIFUL and SHIFT trialsCurrent indications outside the U.S.
Future considerations
4
Case
55 yo WM, PMH history of CAD s/p previous PCI, Ischemic cardiomyopathy, EF 35%, Severe COPD with frequent use of inhalers, comes to your clinic for follow-up, describing low grade stable angina for months (since PCI).
On metoprolol 6.25mg bid, amlodipine 10mg, asa, plavix, statin, ISMN 60mg
BP 110/60, HR 88 at rest. What can we offer him?
5
Elevated Resting Heart Rate Accelerates production of atherosclerosis (Int J
Cardiol 2008;126:302-12)
Associated with coronary plaque disruption (Circulation 2001;126:1477-82)
Framingham Studyprogressive increase in all cause and cardiovascular
mortality in relation to antecedent HR (Am Heart J 1987; 113:1489-94)
Continuous increase in death rates in survivors of Acute MIstarting at HR > 70 (J Am Coll Cardiol 2007;50:823-30)
6
Mechanism of Consequences of Elevated Resting Heart Rate
Increases myocardial oxygen demand Decreases myocardial perfusion by reducing
diastolic perfusion time (Circulation 1979;60:164-9)
Causes vasoconstriction of diseased coronary arteriesSambuceti et al. (Circulation. 1997; 95: 2652-9)
○ 10 patients found to have LAD stenosis (mean 80±5%) vs 7 controls with atypical chest pain, no significant CAD.
○ Pacer lead in RA, flow wire to calculate coronary resistance index○ AdenosinePacing (increments of 20bpm increase)
Adenosine
8
Heart Rate in Cardiovascular Outcomes
Diaz et al. 25,000 patients who had cardiac cath requests for
suspected or proven CADDivided heart rate into quintilesMultivariable Cox PH models
○ Adjusted for beta-blockers use As well as smoking, DM, HTN, gender, age, EF, antiplatelet
and lipid agents
14
Beta-Adrenoceptors Endogenous
catecholamines
activate B-receptors
(Adenylate Cyclase)
Increased cAMP
Increased Ca++ influx
Inotropic Chronotropic
15
Beta Blockers (BB) B1negative chronotropy and inotropyAV conduction delayReduced atrial and ventricular arrythmias
B2BronchoconstrictionPeripheral unopposed alpha constrictionDecrease glycogenolysis
- (contribute to hypoglycemic events) Other antagonize release of renin reduces intraocular pressures
16
Impact of BB
Acute MINorwegian Multicenter
Study Group Timolol *CAPRICORN †ISIS-1 ‡
CHFCOPERNICUS £MERIT-HF €
17
Intolerence of BB Side effects
Bronchoconstriction, AV delay, hypoglycemiaWeight gain, depression, fatigue
BB may not be tolerated in high enough doses to attain heart rates below 70bpm
Acute setting (Acute MI, or CHF), the negative inotropic effect could be deleteriousThis has been shown in dogs (Eur Heart J (2004) 25 (7): 579-586
19
If Current
Sinoatrial Node NA-K inward current Regulated by the
Funny ChannelcAMP
H.F.Brown (1979)• means for acceleration of diastolic depolarization (heart
rate) in adrenergic response
22
Ivabradine Specifically binds the Funny
channelReduces the slope for diastolic
depolarization ○ Prolongs diastolic duration
Does not alter…○ Ventricular repolarization○ Myocardial contractility○ Blood pressure
23
Ivabradine
2005--Approved by the European Medicine Agency Trade: Procoralan, Coralan (India), Corlentor (Italy)
2.5mg, 5mg, 7.5mg. Two times a day
Side Effects (%) Teratogenic
PregnancyBreast feeding
25
Heart rate Reduction during Exercise-inducedMyocardial Ischemia and Stunning
5 dogs with implanted LCx occluder, ultrasound crystals (LV wall thickness), and pacerIvabradine vs atenolol vs saline
○ Administered before or after 10min on treadmill ○ Paced at 150bpm for 6 hours
26Monnet X et al. Eur Heart J 2004;25:579-586
*P<0.05: atenolol and ivabradine significantly different from saline.
Saline (full circles) Ivabradine (open circles) Atenolol (open triangles)
Administration BEFORE Onset of Exercise
27
Monnet X et al. Eur Heart J 2004;25:579-586
*P<0.05: atenolol and ivabradine significantly different from saline. †P<0.05: atenolol significantly different from ivabradine.
Saline (full circles) Ivabradine (open circles) Atenolol (open triangles)
Administration BEFORE Onset of Exercise AND PACED
28
Monnet X et al. Eur Heart J 2004;25:579-586
Administration AFTER Onset of Exercise
*P<0.05: atenolol and ivabradine significantly different from saline. †P<0.05: atenolol significantly different from ivabradine.
Saline (full circles) Ivabradine (open circles) Atenolol (open triangles)
29
Monnet X et al. Eur Heart J 2004;25:579-586
*P<0.05: atenolol and ivabradine significantly different from saline. †P<0.05: atenolol significantly different from ivabradine.
Administration AFTER Onset of ExerciseAND PACED
Saline (full circles) Ivabradine (open circles) Atenolol (open triangles)
30
Ivabradine Trials
Reduces atherosclerosis (Circ 2008;117:2377-87)
Decreases vascular oxidative stressImproves endothelial function
Increases exertional tolerance and time to ischemia in patients with > 3 months angina (Circ 2003;107:817-23)
Non-inferior to Atenolol (Eur Heart J 2005;26:2529-36)
Exercise tolerance, time to angina or ischemia Non-inferior to Amlodipine (Drugs 2007;67(3):393-405)
31
BEAUTIFUL Trial Randomized, double-blinded, placebo controlled
781 centers, 33 countries 11,000 subjects (between 2005 and 2007)
Male (98%), Caucasian (83%), HR>60, EF<40%CAD and on optimal medical management
○ 87% on BB, 89% on ACE/ARBs, 27% Aldo antagonists
Ivabradine vs placebo, followed for 3 years5mg bid, if HR >60 at 2 weeks, increase to 7.5mg
Primary endpoint was a composite of CV death and hospitalizations for MI or CHF
Subgroup analysis: HR>70 (5,400)
38
What Can We Conclude from the BEAUTIFUL Trial?
While there was no difference total cardiovascular mortality
Ivabradine use appears to be a benefit in reducing readmissions due to coronary artery disease (when resting heart rate > 70)1. Acute Myocardial Infarction
2. Coronary Revascularization
39
SHIFT Trial Randomized, double-blinded, placebo controlled 6,500 subjects
Male (76%), Caucasian (89%)Class II – IV heart failure, EF<35%, HR>70bpmAdmission for heart failure in the previous 2 months
On optimal medical management○ 90% on BB, 84% on ACE/ARBs, 60% Aldo antagonists
Ivabradine vs placebo, followed for 3 years Primary endpoint: composite of CV death or
hospital admission for heart failure.
48
What Can We Conclude from the SHIFT Trial?
In patients with all-cause cardiomyopathy (EF<35%), and heart rates > 70bpm,
While there was no difference total cardiovascular mortality,
Ivabradine reduces… 1. Mortality due to Heart Failure
2. Heart failure admissions
49
Current IndicationsEuropean Medicines Agency
“Treatment of symptoms of long-term stable angina in adults (aged over 18 years) with coronary artery disease who have normal sinus rhythm.
It can be used in the following groupsPatients who cannot take or tolerate beta-blockersPatients whose disease is not controlled with beta-
blockers and whose heart rate is above 60bpm.”
50
Future Considerations
Use of Ivabradine in the acute settingAcute myocardial infarctionUpon onset of congestive heart failure?
Diastolic heart failure?
51
Summary
Ivabradine is a selective inhibitor of “Funny” (If) Current in the sinoatrial node.
It causes a pure heart rate reduction.
It is shows cardiovascular benefit when given addition to optimal medical management.
52
Summary Ivabradine use reduces readmissions due to
coronary artery disease (when resting heart rate > 70, EF<40%)1. Acute Myocardial Infarction
2. Coronary Revascularization
In patients with all-cause cardiomyopathy (EF<35%), and heart rates > 70bpm,
Ivabradine reduces… 1. Mortality due to Heart Failure
2. Heart Failure Admissions
53
Case
55 yo WM, PMH history of CAD s/p previous PCI, Ischemic cardiomyopathy, EF 35%, Severe COPD with frequent use of inhalers, comes to your clinic for follow-up, describing low grade stable angina for months (since PCI).
On metoprolol 6.25mg bid, amlodipine 10mg, asa, plavix, statin, ISMN 60mg
BP 110/60, HR 88 at rest. What can we offer him? Ivabradine