Efficacy of Ivabradine in Patient With Both Persistent Atrial Fibrillation and Heart Failure With Reduce Ejection Fraction

Chun-Yao Huang100 enrolled

Overview

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. Previous studies have shown that rate control strategy in AF is non-inferior to rhythm control strategy, in terms of stroke and mortality risk. In addition, rate control strategy is associated with lower risk of hospitalization and non-cardiovascular mortality. Therefore, rate control is an essential strategy to improve quality of life, decrease morbidity and prevent tachycardia-induced cardiomyopathy in AF patients. The recommended rate control agents include beta-blocker, nondihydropyridine calcium-channel blocker (CCB), digoxin and amiodarone. However, in heart failure with reduced ejection fraction patient, the medication of rate control were beta-blocker than digoxin. But several clinical observation study show excess mortality in AF patients. Ivabradine, a If inhibitor, it is well-established that a pacemaker current, If current, is functionally expressed in the sinus node . Previous studies have shown that Ivabradine, If inhibitor, significantly reduces sinus rate and improves prognosis in patients with systolic heart failure. Interestingly, several investigators found that hyperpolarization- activated cyclic nucleotidylated channel 4 current (HCN4), the main isoform of the channel responsible for If current, is also functionally expressed in the Atrioventricular node(AV node). Recent data have shown that inhibition of If current slows AV node conduction in animals and humans. Thus, we want to compare the effect of Ivabradine on ventricular rate with digoxin in this study.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

NONE

Enrollment

100

Conditions

Eligibility

Sex: ALLMin age: 20 YearsMax age: 90 Years

Medical Language ↔ Plain English

Inclusion Criteria: 1. The patient with persistent or permanent atrial fibrillation(24hr ECG) with HFrEF and HFmrEF. 2. After maximal tolerance dose beta-blocker(Bisoprolol 20mg/day，Carvedilol 50mg/day) or intolerant to beta-blocker the resting heart rate from ECG is still faster than 100 or resting heart rate from ECG is greater than 80 but still with symptoms of short of breath and palpitation. 3. Stable heart rhythm medication.(no change of medication in recently one week) 4. Age 20 to 90 years old. 5. The subject must be an adult who can read himself/herself and walk independently. Exclusion Criteria: 1. Used medication with interaction with digoxin : Clarithromycin, Erythromycin, Azithromycin, ritonavir, lopinavir/ritonavir, Doxycycline, Minocycline, tetracycline。 2. Used medication with interaction with ivabradine: voriconazole, posaconazole, fluconazole, Ombitasvir, Dasabuvir, Carbamazepine, Enzalutamide, Fosphenytoin, Mitotane, Phenobarbital, Phenytoin, Rifampicin 3. Cardiogenic shock. 4. History of symptomatic bradycardia. 5. Renal insufficiency:eGFR\<30 ml/min/1.73m2 6. Pregnancy 7. Heart failure due to congenital heart 8. Severe hypotension(\<90/50mmHg)

Outcomes

Primary Outcomes

Heart rate change

To compare Heart Rate change monitored from 24 hr ECG. Test will be performed at Baseline (screening phase, 4 weeks time between screening/Informed consent and Randomization visit) and treatment completion (Visit 5/Week 16). Total treatment phase is 16 weeks.

Time frame: 24 hr ECG test will be performed at Screening phase and End of Treatment visit(Visit5/Week 16).

6 minute walk test change

To compare 6 minute walking test walking distance change between Randomization visit(Visit 1/Week 0) and treatment completion(Visit 5/Week 16). Total Treatment phase is 16 weeks.

Time frame: Test will be performed at Randomization visit (V1/Week0) and treatment completion (Visit 5/Week 16).

N-terminal pro-brain natriuretic peptide(NT-Pro BNP) change

To compare NT-Pro BNP change from blood sample collected at Baseline (screening phase, 4 weeks time between screening/informed consent and Randomization visit) and treatment completion (Visit 5/Week 16). Total treatment phase is 16 weeks.

Time frame: Blood sample will be collected at Screening phase and End of Treatment visit(Visit5/Week 16).

1-10 Borg Rating of Perceived Exertion Scale change

To compare 1-10 Borg Rating of Perceived Exertion Scale change between Randomization visit (Visit1/Week0) and treatment completion (Visit 5/Week 16). Total Treatment phase is 16 weeks. The number 1-10 Borg Rating of Perceived Exertion Scale will be obtained pre and post 6 minutes walk test. The value of 1-10 Borg Rating of Perceived Exertion Scale pre 6 minutes walking test will be compared between Randomization visit (Visit1/Week0) and treatment completion (Visit 5/Week 16), and the same type of comparison will be performed for 1-10 Borg Rating of Perceived Exertion Scale values post 6 minute walk test. Rating score is as below: 0=Rest, 1=really easy, 2=easy, 3=moderate, 4=sort of hard, 5=hard, 6= between 5 and 7, 7=really hard, 8=between 7 and 9, 9=really really hard, 10=Maximal: just like my hardest race. Decrease in score value compared between Randomization visit (Visit1/Week0) and treatment completion (Visit 5/Week 16) represents better outcome.

Time frame: Borg's score will be tested at Randomization visit (V1/Week0) and treatment completion (Visit 5/Week 16).