Ivabradine (Ivabradine Hydrochloride)
Also sold as: Coralan, Iva, Ivabid
Pregnancy
Cat X
Lactation
Avoid
Schedule
H
Forms
Tablet 5mg +2
Indications
- Chronic heart failure with reduced ejection fraction (HFrEF) — in sinus rhythm with HR ≥75 bpm despite optimal beta-blocker or beta-blocker intolerant
- Stable angina — in sinus rhythm with HR ≥70 bpm, in combination with or unable to tolerate beta-blockers
Adult Dosing
Chronic heart failure (HFrEF)
5 mg twice daily
Start 5mg BD; after 2 weeks, increase to 7.5mg BD if resting HR >60 bpm and tolerated; reduce to 2.5mg BD if resting HR <50 bpm or symptomatic bradycardia
Use only in sinus rhythm with resting HR ≥75 bpm. Add to maximally tolerated beta-blocker dose. Reduces HF hospitalization (SHIFT trial — 18% reduction). Not indicated in AF.
Stable angina
5–7.5 mg twice daily
Start 5mg BD (2.5mg BD in elderly); titrate to 7.5mg BD after 3–4 weeks if HR >60 bpm; target resting HR 55–60 bpm
Reduces angina episodes by reducing heart rate without affecting contractility or blood pressure
Renal Dose Adjustment
| CrCl / eGFR | Dose Adjustment |
|---|---|
| CrCl ≥15 mL/min | No dose adjustment required |
| CrCl <15 mL/min | Insufficient data — use with extreme caution or avoid |
Hepatic Adjustment
Mild hepatic impairment: no dose adjustment. Moderate hepatic impairment: use with caution; may increase ivabradine exposure. Severe hepatic impairment: CONTRAINDICATED.
Pregnancy & Lactation
Pregnancy: Category X
CONTRAINDICATED in pregnancy. Animal studies show embryotoxicity and teratogenicity. No adequate human data. Must use effective contraception during treatment. If pregnancy occurs, discontinue immediately.
Lactation: Avoid
Animal data shows excretion into breast milk. Potential adverse effects on infant cardiac function. Breastfeeding should be discontinued if ivabradine is required.
Top Drug Interactions
| Interacting Drug | Effect | Severity |
|---|---|---|
| Diltiazem / Verapamil (CYP3A4 inhibitors AND heart rate-lowering agents) | CONTRAINDICATED — both inhibit ivabradine metabolism (raising levels) AND additively reduce heart rate; risk of severe, potentially fatal bradycardia and AV block | Major |
| Strong CYP3A4 inhibitors (ketoconazole, itraconazole, clarithromycin, ritonavir, nefazodone) | Markedly increase ivabradine plasma levels (7–8 fold) — profound bradycardia risk. CONTRAINDICATED with strong CYP3A4 inhibitors. | Major |
| Amiodarone / Digoxin | Additive bradycardia and AV node depression — monitor HR and ECG closely; avoid if resting HR <60 bpm | Moderate |
| Moderate CYP3A4 inhibitors (fluconazole, grapefruit juice) | Increase ivabradine levels 2-fold — reduce ivabradine dose; avoid grapefruit juice | Moderate |
| CYP3A4 inducers (rifampicin, phenytoin, carbamazepine, St. John's Wort) | Reduce ivabradine levels significantly — may require dose increase; monitor heart rate response | Moderate |
| QT-prolonging drugs | Ivabradine itself does not prolong QT but bradycardia can unmask/worsen QT prolongation — monitor ECG | Moderate |
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Side Effects
Common
- Luminous phenomena (phosphenes) — visual brightness in visual field; 15% incidence; usually transient and benign
- Bradycardia (dose-dependent) — most common serious adverse effect
- Headache
- Dizziness
- Blurred vision
- Atrial fibrillation (paradoxical — monitor for new-onset AF)
Serious / Discontinue If
- Symptomatic bradycardia (HR <40 bpm) — dose-dependent; discontinue if HR <50 bpm with symptoms
- Atrial fibrillation — 5% incidence (higher than placebo in SIGNIFY trial); monitor for AF development; STOP ivabradine if AF occurs (not indicated in AF)
- Atrioventricular block (first degree most common; complete heart block rare)
- Syncope (secondary to severe bradycardia)
- Visual disturbances (phosphenes can impair driving in dim light)
Contraindications
- Atrial fibrillation or flutter (mechanism depends on sinus node — no effect in AF)
- Resting heart rate <70 bpm before initiation (heart failure) or <60 bpm (angina)
- Cardiogenic shock
- Severe hypotension (SBP <90 mmHg)
- Sick sinus syndrome or SA block (without functioning pacemaker)
- Complete AV block (without functioning pacemaker)
- Concurrent diltiazem or verapamil use (CONTRAINDICATED)
- Concurrent strong CYP3A4 inhibitors (ketoconazole, clarithromycin, ritonavir)
- Severe hepatic impairment
- Pregnancy
Available Indian Brands
| Brand | Manufacturer | Price (approx) |
|---|---|---|
| Coralan 5mg | Servier India | ₹145/10 tablets |
| Ivabid 5mg | Sun Pharma | ₹89/10 tablets |
| Iva 5mg | Cipla | ₹95/10 tablets |
Monitoring Required
- Resting heart rate — before initiation and after 2 weeks of each dose change; target 55–60 bpm in angina, do not allow to drop <50 bpm
- ECG — PR interval, rhythm (check for AF development at each visit)
- BP — ivabradine does not lower BP; monitor for underlying hemodynamic changes
- Symptoms of HF decompensation (weight gain, dyspnea, edema)
- Visual symptoms — phosphenes (usually mild and self-limiting; counsel patient)
- Rhythm monitoring — new-onset palpitations or irregular pulse may indicate AF (stop drug)
- LFTs — in hepatic impairment patients (drug metabolism)
Patient Counseling Points
- You may see flashes of light (especially when moving from dark to light) — this is a known side effect called phosphenes; it is not dangerous and usually resolves. Avoid driving at night initially.
- Check your pulse daily — if consistently below 50 beats per minute, contact your doctor
- Do NOT take with diltiazem (Dilzem, Angizem) or verapamil — extremely dangerous combination
- Avoid grapefruit and grapefruit juice — increases drug levels
- This drug only controls heart rate — it does NOT lower blood pressure
- If you develop irregular heartbeat or palpitations, inform your doctor immediately — may need to stop the drug
- Women of childbearing age must use contraception — drug is harmful in pregnancy
- Inform your doctor of all medications including antibiotics (clarithromycin, erythromycin) — can interact dangerously
- Take with food, twice daily (morning and evening)
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Clinically reviewed by: Dr. Priya Menon, DM (Cardiology), PGIMER Chandigarh
Last reviewed: 2026-04-01
References
- Drugs.com — Ivabradine Monograph
- CIMS India — Ivabradine
- SHIFT Trial — Ivabradine in HFrEF (Lancet 2010)
- SIGNIFY Trial — Ivabradine in Stable CAD (NEJM 2014)
- ESC Heart Failure Guidelines 2021
- ACC/AHA Heart Failure Guidelines 2022
- Indian National Formulary 2023