If Channel (Funny Current) Inhibitor Pregnancy: Contraindicated during pregnancy and breast-feeding, and in women of childbearing potential not using appropriate contraceptive measures. Animal studies have shown embryotoxic and teratogenic effects; the potential risk for humans is unknown. Animal studies indicate ivabradine is excreted in milk — women needing treatment should stop breast-feeding (UK SPC §4.3/§4.6).

Ivabradine

Brand names: Procoralan

Ivabradine is a heart-rate-lowering agent used in chronic stable angina and in chronic heart failure with reduced ejection fraction in patients in sinus rhythm with an elevated heart rate.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Chronic stable angina pectoris: starting dose should not exceed 5 mg twice daily in patients aged below 75 years; after three to four weeks the dose may be increased to the next higher dose if the patient is still symptomatic, the initial dose is well tolerated and resting heart rate remains above 60 bpm. Chronic heart failure: usual recommended starting dose 5 mg twice daily; after two weeks increase to 7.5 mg twice daily if resting heart rate is persistently above 60 bpm, or decrease to 2.5 mg twice daily if it is persistently below 50 bpm

Route: Oral — tablets must be taken with meals

Frequency: Twice daily, once in the morning and once in the evening

Max: 7.5 mg twice daily (the maintenance dose should not exceed 7.5 mg twice daily)

It is recommended that the decision to initiate or titrate treatment takes place with the availability of serial heart rate measurements, ECG or ambulatory 24-hour monitoring. Available doses are 2.5 mg (one half of a 5 mg tablet), 5 mg and 7.5 mg twice daily. Angina: if there is no improvement in symptoms within 3 months of starting, treatment should be discontinued; discontinuation should also be considered if there is only limited symptomatic response and no clinically relevant reduction in resting heart rate within three months. All indications: if resting heart rate decreases below 50 bpm or the patient experiences symptoms of bradycardia (dizziness, fatigue, hypotension), titrate the dose downward, including to the lowest dose of 2.5 mg twice daily, and monitor heart rate after reduction; treatment must be discontinued if heart rate remains below 50 bpm or symptoms of bradycardia persist despite dose reduction. Heart failure: treatment must only be initiated in patients with stable heart failure and the treating physician should be experienced in the management of chronic heart failure; maintain 5 mg twice daily if heart rate is between 50 and 60 bpm; up-titrate to the next higher dose if heart rate is persistently above 60 bpm. Elderly: in patients aged 75 years or more, a lower starting dose should be considered (2.5 mg twice daily) before up-titration if necessary. Hepatic impairment: no dose adjustment in mild impairment; caution in moderate impairment; contraindicated in severe hepatic insufficiency. Paediatric: safety and efficacy in children under 18 years have not been established for chronic heart failure and no recommendation on posology can be made; no data are available for symptomatic treatment of chronic stable angina.

Dose adjustments

Renal

No dose adjustment is required in patients with renal insufficiency and creatinine clearance above 15 mL/min. No data are available in patients with creatinine clearance below 15 mL/min — use with precaution in this population (UK SPC §4.2).

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to the active substance or to any of the excipients
Resting heart rate below 70 beats per minute prior to treatment
Cardiogenic shock; acute myocardial infarction
Severe hypotension (<90/50 mmHg)
Severe hepatic insufficiency
Sick sinus syndrome; sino-atrial block; third-degree AV block
Unstable or acute heart failure; unstable angina
Pacemaker dependence (heart rate imposed exclusively by the pacemaker)
Combination with strong CYP3A4 inhibitors such as azole antifungals (ketoconazole, itraconazole), macrolide antibiotics (clarithromycin, oral erythromycin, josamycin, telithromycin), HIV protease inhibitors (nelfinavir, ritonavir) and nefazodone
Combination with verapamil or diltiazem (moderate CYP3A4 inhibitors with heart-rate-reducing properties)
Pregnancy, lactation, and women of childbearing potential not using appropriate contraceptive measures

Side effects

Luminous phenomena (phosphenes) — very common (14.5%); transient enhanced brightness in a limited area of the visual field, usually triggered by sudden variations in light intensity, generally starting within the first two months
Bradycardia — common (3.3%); also first-degree AV block (prolonged PQ interval), ventricular extrasystoles and atrial fibrillation (common)
Headache, generally during the first month of treatment, and dizziness possibly related to bradycardia (common)
Blurred vision (common); uncontrolled blood pressure (common)
Uncommon: syncope, palpitations, supraventricular extrasystoles, prolonged QT interval, hypotension, vertigo, dyspnoea, nausea, constipation, diarrhoea, muscle spasms, angioedema, rash
Very rare: second- and third-degree AV block, sick sinus syndrome

Interactions

Strong CYP3A4 inhibitors (azole antifungals, macrolide antibiotics, HIV protease inhibitors, nefazodone) — contraindicated (SPC §4.3)
Verapamil or diltiazem — concomitant use is contraindicated (SPC §4.3/§4.4)
Moderate CYP3A4 inhibitors and grapefruit juice — avoid concomitant use (US FDA label §7.1)
CYP3A4 inducers (St John's wort, rifampicin, barbiturates, phenytoin) — avoid concomitant use as they decrease ivabradine plasma concentrations (US FDA label §7.1)
Negative chronotropes, including beta-blockers — the risk of bradycardia increases with concomitant administration; monitor heart rate (US FDA label §7.2)
Amiodarone or potent class I anti-arrhythmics — atrial fibrillation has been more common with concomitant use (SPC §4.4)
eMC §4.5 was not captured in full in this source bundle — the UK interaction list should be verified by the clinician

Clinical monograph

How it works

It selectively inhibits the funny (If) current in the sinoatrial node, slowing the heart rate without affecting myocardial contractility or blood pressure.

Prescribing in practice

It works only in sinus rhythm and is ineffective and inappropriate in atrial fibrillation, and excessive bradycardia is a key risk.
Luminous visual phenomena (phosphenes) are characteristic and usually transient but can affect driving in changing light.
Avoid co-administration with strong CYP3A4 inhibitors and other heart-rate-lowering or QT-affecting drugs that increase bradycardia risk.

Monitoring

Monitor heart rate and rhythm, and review for new atrial fibrillation, particularly after dose changes.

Counselling the patient

You may notice brief flashes or halos of light, especially with sudden changes in brightness; this is usually harmless.
Report a slow pulse, dizziness, breathlessness or palpitations.
Avoid grapefruit juice, which can raise drug levels.

Evidence & guidelines

The SHIFT trial showed ivabradine reduced heart failure hospitalisations in selected patients in sinus rhythm, informing NICE recommendations.

Reference: SHIFT trial (Swedberg et al. NEJM 2010); NICE TA267; MHRA SPC Procoralan; ESC HF Guidelines (2021); Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways