Recommendation 34: We recommend that ivabradine be considered in patients with HFrEF, who remain symptomatic despite treatment with appropriate doses of GDMT, with a resting heart rate > 70 bpm, in sinus rhythm and a prior HF hospitalization within 12 months, for the prevention of cardiovascular death and HF hospitalization (Strong Recommendation, Moderate Quality Evidence).

Values and preferences: High value is placed on the improvement of cardiovascular death and HF hospitalizations as adjunctive therapy to standard HF medication treatments in a selected HF population. The health economic implications are unknown. Differing criteria for heart rate eligibility have been approved by various regulatory authorities ranging from 70 to 77 beats per minute with the trial entry criteria of 70 bpm.

• Every effort should be made to achieve target or maximally tolerated doses of beta-blockers prior to initiation of ivabradine.
• Ivabradine has no effect on blood pressure or myocardial contractility.