Indications: lowers the heart rate by its action on the sinus node. It is licensed for the treatment of angina in patients who are in normal sinus rhythm in combination with a beta-blocker, or when beta-blockers are contra- indicated or not tolerated. Ivabradine, in combination with standard therapy including a beta-blocker (unless contra-indicated or not tolerated), is also licensed for mild to severe stable chronic heart failure in patients who are in sinus rhythm.

Cautions: monitor for atrial fibrillation or other arrhythmias (treatment ineffective); monitor for bradycardia, especially after any dose increase, and discontinue if resting heart rate persistently below 50 beats per minute or continued symptoms of bradycardia despite dose reduction; intraventricular conduction defects; hypotension (avoid if severe); retinitis pigmentosa; elderly.

Contra-indications: for angina, do not initiate if heart rate below 60 beats per minute; for heart failure, do not initiate if heart rate below 75 beats per minute; unstable or acute heart failure; cardiogenic shock; acute myocardial infarction; unstable angina; immediately after cerebrovascular accident; sick-sinus syndrome; sino-atrial block; patients dependent on pacemaker; second- and third-degree heart block; congenital QT syndrome Hepatic impairment: manufacturer advises caution in moderate impairment; avoid in severe impairment.

Renal impairment: manufacturer advises use with caution if eGFR less than 15 ml/minute/1.73 m2—no information available

Pregnancy: manufacturer advises avoid—toxicity in animal studies.

Breast feeding: present in milk in animal studies— manufacturer advises avoid

Side Effects: bradycardia, first-degree heart block, ventricular extrasystoles, headache, dizziness, visual disturbances including phosphenes and blurred vision; less commonly nausea, constipation, diarrhoea, palpitations, supraventricular extrasystoles, dyspnea, angioedema, vertigo, muscle cramps, eosinophilia, hyperuricaemia, raised plasma-creatinine concentration, rash; very rarely atrial fibrillation, second- and third- degree heart block, sick sinus syndrome

Dose: Angina, initially 5 mg twice daily, increased if necessary after 3–4 weeks to 7.5 mg twice daily (if not tolerated reduce dose to 2.5–5 mg twice daily); ELDERLY initially 2.5 mg twice daily.

Heart failure, initially 5 mg twice daily, increased if necessary after 2 weeks to 7.5 mg twice daily (if not tolerated reduce dose to 2.5 mg twice daily)