Ivabradine

So if someone is not treating your blood volume with s- with any one of those medicines I just mentioned, that's where really you need to start.

Now, after that, you can add on things like beta blockers, or you can add on things like, um, a medicine called Ivabradine, which is a medicine that directly work on the heart.

And, you know, there's Guanfacine, which is, which is a medicine that decreases your norepinephrine or your adrenaline output.

So there's all of these other add-ons that we can add, but the big thing that I always try to teach when I give a lecture or when I talk to a group of patients or g- to g- any group of physicians, is that the blood volume really needs to improve first.

It is a reasonable addition in patients with recurrent events despite the four pillars.

Ivabradine is indicated in sinus rhythm with a heart rate of 70 or more despite maximally tolerated beta blocker based on the SHIFT trial.

Digoxin may help reduce hospitalization as the DIG trial showed, particularly for rate control in atrial fibrillation, but we use low doses and monitor levels.

Hydralazine and I, so SOC, bi-di-nitrate are useful in patients who cannot tolerate renin-angiotensin blockade and in self-identified black patients based on the A-HEFT trial.

Ranolazine can prolong the QT interval, causes dizziness and constipation, and interacts with drugs metabolized by CYP3A4.

Ivabradine, which slows the sinus rate, can cause visual phenomena called phosphenes, bradycardia, and atrial fibrillation.

It should only be used in sinus rhythm, and the SIGNIFY trial showed no benefit and possible harm when used at high doses in stable patients without heart failure, so it's for symptom control, not prognosis.

Nicorandil causes headache and rarely painful ulcers of the mouth, skin, or bowel.