The Usefulness of Prioritization of Ivabradine Before Beta-Blockers in a Heart Failure Patient Suffering From Intra-hemodialysis Hypotension

Depressed cardiac systolic function in hemodialysis patients occurs for a variety of reasons and is a clinical problem. Beta-blockers are a key drug in the treatment of heart failure; however, hypotension may occur, particularly in dialysis patients, thereby complicating dialysis. Ivabradine has the unique property of a negative chronotropic effect only, without the negative inotropic effect. A 55-year-old woman who underwent dialysis presented with dyspnea and fatigue even at rest due to low cardiac systolic function. The left ventricular ejection fraction (LVEF) was 30%. Medications for heart failure, such as carvedilol and enalapril, were initiated; however, they were discontinued owing to intradialytic hypotension. Subsequently, her heart rate increased to over 100 beats per minute (bpm); therefore, we administered 2.5 mg of ivabradine before beta-blockers, which reduced her heart rate by approximately 30 bpm without a significant blood pressure decrease. Moreover, her blood pressure stabilized during dialysis. After two weeks, we added 1.25 mg of bisoprolol and adjusted the dose to 0.625 mg. After seven months of treatment with 2.5 mg ivabradine and 0.625 mg bisoprolol, systolic cardiac function significantly improved to 70% of LVEF. Prioritizing ivabradine over beta-blockers may not cause intradialytic hypotension; even low doses of ivabradine and bisoprolol were considered effective heart failure therapies.