Early administration of ivabradine in patients with acute anterior ST-elevation myocardial infarction: a prospective, randomized, open-label study on in-hospital and short-term major adverse cardiac events and left ventricular function

Abstract Background Elevated heart rate (HR) in acute anterior ST-elevation myocardial infarction (STEMI) increases myocardial oxygen demand and limits perfusion, worsening outcomes. Ivabradine selectively reduces HR without negative inotropy. This open-label randomized controlled study investigates the efficacy and safety of early ivabradine administration in patients with acute anterior STEMI. Methods This randomized controlled prospective study included 300 patients with acute anterior STEMI (sinus rhythm, HR > 70 bpm) at Ain Shams University hospitals. Patients were randomized 1:1 to receive either standard beta-blocker therapy plus ivabradine (Ivabradine group, n = 150) or standard beta-blocker therapy alone (Control group, n = 150). Echocardiographic assessors and clinical event adjudicators were blinded to treatment allocation. Primary outcomes were changes in left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), HR, cardiac biomarkers (CK-MB, Troponin), and the incidence of major adverse cardiac events (MACE) at 3-month follow-up. Procedural variables (door-to-balloon time, final TIMI flow, myocardial blush grade, no-reflow phenomenon), Killip class, arrhythmic events, and guideline-directed medical therapy use were documented. Results Baseline demographic, angiographic, and medical therapy characteristics were similar between groups. At 3 months, the Ivabradine group demonstrated a significantly greater improvement in LVEF compared to controls (mean ± SD: 51.96 ± 6.09% vs. 49.79 ± 4.47%, p < 0.001). LVEDV significantly decreased in the Ivabradine group (from 101.44 ± 13.84 mL to 83.65 ± 8.76 mL) but increased in the control group (from 100.49 ± 12.73 mL to 120.67 ± 10.15 mL) ( p < 0.001 for final LVEDV between groups). Final HR was significantly lower in the Ivabradine group (62.31 ± 1.79 vs. 76.13 ± 3.54 bpm, p < 0.001). The incidence of heart failure hospitalization (1.3% vs. 11.3%, p < 0.001) and total MACE (12.7% vs. 32.0%, p < 0.001) were significantly reduced in the Ivabradine group. No significant differences were observed in no-reflow rates (12.0% vs. 14.7%, p = 0.491) or ventricular arrhythmias (2.7% vs. 4.0%, p = 0.523) between groups. Conclusion Early administration of ivabradine in patients with acute anterior STEMI and elevated HR without cardiogenic shock was associated with better heart-rate control and favorable short-term echocardiographic outcomes, while the clinical outcome findings require confirmation in prospectively registered, adequately powered multicenter trials. These findings apply to Killip class I-III patients; Killip class IV patients (cardiogenic shock) were excluded from this study.