Precision Use of Ivabradine in Contemporary HFrEF: From Heart Rate Reduction to Physiological Optimization

Aims To reassess the contemporary role of ivabradine in heart failure with reduced ejection fraction and propose a precision-oriented framework for individualized heart rate management in the era of foundational guideline-directed medical therapy. Methods and Results Ivabradine selectively reduces sinus rate without direct negative inotropic effects, with established benefits in selected patients with heart failure with reduced ejection fraction and persistent sinus tachycardia. However, recent meta-analyses differ substantially in study populations, endpoint availability, and background therapy, limiting firm conclusions regarding the incremental effect of ivabradine on major clinical outcomes in the contemporary treatment era. This review integrates established and emerging evidence, with particular emphasis on the conceptual distinction between maladaptive and compensatory tachycardia, candidate individualized and dynamic heart-rate strategies, transmitral filling patterns, atrioventricular timing, and electrophysiological effects beyond the sinoatrial node. Evidence in acute heart failure, atrial fibrillation, and acute myocardial infarction is also considered. Ivabradine should complement rather than replace foundational guideline-directed medical therapy, while physiology-guided titration remains investigational. Conclusion The contemporary role of ivabradine may extend beyond fixed heart rate thresholds toward individualized physiological optimization. The immediate objective of such an approach is to improve filling, hemodynamic tolerance, and treatment response rather than to assume a direct survival benefit. Whether physiology-guided ivabradine therapy improves heart failure hospitalization or survival requires prospective validation before such strategies can be incorporated into routine practice.