Managing Ischaemic Heart Disease with Concomitant Heart Failure
This patient has ischaemic heart disease (IHD) and is already on metoprolol 50 mg twice a day, yet has a persistently elevated resting heart rate of 90 beats/minute. He now also shows signs of heart failure (HF). The question asks which drug can be safely added on top of an existing beta-blocker in this setting.
Why Ivabradine Is the Correct Answer
Ivabradine selectively inhibits the If ("funny") current in the sinoatrial (SA) node, producing pure heart-rate reduction without any negative inotropic effect and without lowering blood pressure. This makes it uniquely suited to this patient:
- It is specifically indicated in patients with chronic heart failure with reduced ejection fraction (HFrEF) who remain in sinus rhythm with a resting heart rate ≥70 bpm despite being on a maximally tolerated dose of beta-blocker (or when beta-blockers cannot be up-titrated further).
- Because its mechanism is different from and complementary to beta-blockade, it can be safely added to, not substituted for, metoprolol, giving further heart-rate control without additive negative inotropy or hypotension.
- Heart-rate reduction with ivabradine has been shown to reduce hospitalizations for worsening heart failure in this population (SHIFT trial), making it the rational add-on here.
Why the Other Options Are Incorrect
- Ranolazine: An anti-anginal agent that works by inhibiting the late sodium current; it is used for chronic stable angina refractory to other therapies, but it has no established role in heart failure management and is not indicated simply for a fast resting heart rate with HF signs.
- Diclofenac: An NSAID. NSAIDs cause sodium and water retention and can precipitate or worsen heart failure, and they increase cardiovascular risk in patients with IHD. This drug should be avoided, not added, in this patient.
- Prednisolone: A corticosteroid. Corticosteroids promote sodium and fluid retention and can worsen heart failure; they have no role in the routine management of IHD-related heart failure and are reserved only for specific inflammatory conditions of the heart, which is not suggested here.
Conclusion
In a patient with IHD on beta-blocker therapy who has a persistently high heart rate and new signs of heart failure, Ivabradine is the appropriate add-on drug, as it further reduces heart rate through a beta-blocker-independent mechanism while being safe to combine with metoprolol in HFrEF.
Important Questions from Heart Failure
High output cardiac failure is caused by which of the following diseases ?
1. Beri-beri
2. Severe anaemia
3. Thyrotoxicosis
Select the correct answer using the code given below:
- Kussmaul's sign is present in all of the following conditions, EXCEPT:
- Which of the following electro-cardio-graphic findings are manifestations of digitalis intoxication?
1. Ventricular bigeminy
2. Ventricular tachycardia
3. Atrial flutter
4. Atrial tachycardia with variable block
Select the correct answer using the code given below: - A 35-year-old labourer worker consulted a local medical practitioner for recurrent attack of chest pain. His elder brother had similar complaint and died at the age of 40 years. The labourer worker was advised to take sublingual nitroglycerin at the time of chest pain. But after taking nitroglycerin, the chest pain increased in intensity. Which one of the following is most likely ?
- The treatment of choice for a 32 year old male patient of severe mitral stenosis (Rheumatic) with thickened and calcified valves on echocardiography is:
