Ivabradine Versus Up-titrated Bisoprolol for Persistent Tachycardia After Primary PCI in Anterior STEMI: A...

Persistent sinus tachycardia after primary percutaneous coronary intervention (PCI) for anterior ST-segment elevation myocardial infarction (STEMI) predicts adverse left-ventricular (LV) remodeling and major adverse cardiovascular events (MACE), yet β-blocker up-titration is frequently limited by hypotension or LV dysfunction. We tested whether adjunctive ivabradine achieves superior heart-rate control and cardiac recovery compared with continued bisoprolol titration alone.

In this single-center, pragmatic, open-label, superiority randomized controlled trial, 140 patients with first-time anterior STEMI and resting heart rate ≥ 70 bpm despite maximally tolerated bisoprolol were assigned 1:1 to ivabradine add-on (5 mg twice daily) or continued bisoprolol titration. The primary endpoint was 12-month major adverse cardiovascular events (MACE). Secondary endpoints included change in resting heart rate from baseline to 12 months, left ventricular ejection fraction (LVEF), and B-type natriuretic peptide (BNP) levels.

Throughout 12 months, ivabradine reduced heart rate by ≈ 10 bpm versus control (P < 0.05 for all time-points) and improved LVEF earlier (Δ + 5.7% at 6 months, P = 0.015; sustained at 12 months, P = 0.032). BNP declined more rapidly in the ivabradine group at 3 months (P = 0.038). MACE-free survival did not differ between groups (82.9% vs. 80.0%, log-rank P = 0.664). Age and baseline LVEF, but not ivabradine allocation, independently predicted MACE. Adverse events were infrequent.

In anterior-STEMI patients restricted by β-blocker ceiling, ivabradine add-on safely achieves sustained heart-rate reduction and early ventricular recovery without affecting 12-month MACE. Larger, blinded trials are warranted to confirm long-term efficacy and cost-effectiveness.