• Aileen Chen, Nadia Elia, Jelena Dunaiceva, Alain Rudiger, Bernhard Walder, and Bollen Pinto Bernardo B Division of Anaesthesiology, Department of Acute Medicine, Geneva University Hospitals, Switzerland; Perioperative Basic, Translational and Clinic.
• Division of Anaesthesiology, Department of Acute Medicine, Geneva University Hospitals, Switzerland; Perioperative Basic, Translational and Clinical Research Group, Division of Anaesthesiology, Geneva University Hospitals, Geneva, Switzerland.
• Br J Anaesth. 2020 Jun 1; 124 (6): 726-738.

BackgroundIvabradine lowers heart rate (HR) without affecting contractility or vascular tone. It is licensed for HR control in chronic heart diseases. We performed a systematic review and meta-analyses to examine whether ivabradine could decrease major adverse cardiovascular events (MACE) and mortality in critically ill patients.MethodsWe searched Medline, Embase, Cochrane Library, and Web of Science for RCTs. Trial quality was assessed using the Cochrane risk of bias tool. Random-effects meta-analyses were performed if at least three trials or 100 patients were available. Results are reported as weighted mean difference (WMD), odds ratio (OR), and 95% confidence intervals (CIs). Trial sequential analyses were performed to estimate the sample size needed to reach definitive conclusions of efficacy or futility.ResultsWe included 13 RCTs (n=1497 patients). We found no evidence of an impact of ivabradine on MACE (three RCTs, 819 patients; OR=0.77; 95% CI, 0.53-1.11) or mortality (10 RCTs, 1356 patients; OR=1.07; 95% CI, 0.63-1.82), but sample sizes were not reached to allow definitive conclusions. Compared with placebo or standard care, ivabradine reduced HR (eight RCTs, 464 patients; WMD, -9.5 beats min-1; 95% CI, -13.3 to -5.8). Risk of bradycardia was not different between ivabradine and control (five RCTs, 434 patients; OR=1.2; 95% CI, 0.60-2.38). Risk of bias was overall high or unclear.ConclusionsIvabradine reduces HR compared with placebo or standard care. The effect on MACE or mortality in acute care remains unclear. Further RCTs powered to detect changes in clinically relevant outcomes are warranted.Clinical Trial RegistrationProspero CRD42018086109.Copyright © 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

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