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Hemodynamic effects of ivabradine use in combination with intravenous inotropic therapy in advanced heart failure

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Abstract

Intravenous inotropic therapy can be used in patients with advanced heart failure, as palliative therapy or as a bridge to cardiac transplantation or mechanical circulatory support, as well as in cardiogenic shock. Their use is limited to increasing cardiac output in low cardiac output states and reducing ventricular filling pressures to alleviate patient symptoms and improve functional class. Many advanced heart failure patients have sinus tachycardia as a compensatory mechanism to maintain cardiac output. However, excessive sinus tachycardia caused by intravenous inotropes can increase myocardial oxygen consumption, decrease coronary perfusion, and at extreme heart rates decrease ventricular filling and stroke volume. The limited available hemodynamic studies support the hypothesis that adding ivabradine, a rate control agent without negative inotropic effect, may blunt inotrope-induced tachycardia and its associated deleterious effects, while optimizing cardiac output by increasing stroke volume. This review analyzes the intriguing pathophysiology of combined intravenous inotropes and ivabradine to optimize the hemodynamic profile of patients in advanced heart failure.

Illustration of the beneficial and deleterious hemodynamic effects of intravenous inotropes in advanced heart failure, and the positive effects of adding ivabradine.

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Abbreviations

LV:

Left ventricle

cAMP:

Cyclic adenosine monophosphate

HCN:

Hyperpolarization-activated cyclic nucleotide-gated

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Authors and Affiliations

  1. Department of Internal Medicine, University of Florida, Gainesville, FL, USA

    Mohammed Elzeneini

  2. Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA

    Juan M. Aranda Jr, Mohammad Al-Ani, Mustafa M. Ahmed, Alex M. Parker & Juan R. Vilaro

  3. Advanced Heart Failure & Transplant Cardiology, University of Florida, 1329 SW 16th Street, Suite 5130, PO Box 100288, Gainesville, FL, 32608, USA

    Juan M. Aranda Jr, Mohammad Al-Ani, Mustafa M. Ahmed, Alex M. Parker & Juan R. Vilaro

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Juan Aranda and Juan Vilaro had the idea for the article.

Mohammed Elzeneini and Mohammad Al-Ani contributed to the literature review.

Mohammed Elzeneini contributed to the data analysis.

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Correspondence to Juan R. Vilaro.

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Elzeneini, M., Aranda, J., Al-Ani, M. et al. Hemodynamic effects of ivabradine use in combination with intravenous inotropic therapy in advanced heart failure. Heart Fail Rev 26, 355–361 (2021). https://doi.org/10.1007/s10741-020-10029-x

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