Ivabradine of no benefit in angina pectoris

Use of ivabradine for angina pectoris caused by coronary artery disease does not seem to improve patient outcomes and may even be harmful, as it increases the risk of adverse events such as atrial fibrillation, according to the results of a systematic review and meta-analysis.

European Society of Cardiology guidelines recommend using ivabradine in chronic coronary syndromes. However, prior researches had produced mixed findings. For example, the drug helped reduce the incidence of adverse outcomes in patients with stable coronary artery disease and left-ventricular systolic dysfunction in the BEAUTIFUL trial.

On the other hand, ivabradine had a null effect in patients with stable coronary artery disease without clinical heart failure in the SIGNIFY trial.

The current meta-analysis included 47 randomized clinical trials evaluating the effect of ivabradine against placebo (n=20) or no intervention (n=27) in patients with angina pectoris due to coronary artery disease (n=35,797). The risk of bias was high across all trials.

Pooled data revealed that compared with control, ivabradine did not improve the following outcomes: all-cause mortality (risk ratio [RR], 1.04, 95 percent confidence interval [CI], 0.96–1.13), quality of life (standardized mean difference, −0.05, 95 percent CI, −0.11 to 0.01), cardiovascular mortality (RR, 1.07, 95 percent CI, 0.97–1.18), and myocardial infarction (RR, 1.03, 95 percent CI, 0.91–1.16).

Furthermore, the drug contributed to an increased risk of serious adverse events (RR, 1.07, 95 percent CI, 1.03–1.11), especially bradycardia, prolonged QT interval, photopsia, atrial fibrillation, and hypertension. There also was a risk increase seen for nonserious adverse events (RR, 1.13, 95 percent CI, 1.11–1.16).

Ivabradine showed a beneficial effect on angina frequency (mean difference [MD], 2.06, 95 percent CI, 0.82–3.30) and stability (MD, 1.48, 95 percent CI, 0.07–2.89), but the effect sizes were small and possibly irrelevant to patients.

Based on current evidence, guidelines should be reassessed and the use of ivabradine for angina pectoris be reconsidered.