Metoprolol vs ivabradine in patients with mitral stenosis in sinus rhythm Vikas Agrawal a, ⁎, Niraj Kumar b , Balalji Lohiya a , Bhupendra K. Sihag a , Rajpal Prajapati a , T.B. Singh c , Geetha Subramanian a a Department of Cardiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India b Department of Cardiology, Medanta the Mediciti, Gurgaon, Haryana, India c Division of Biostatistics, Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India abstract article info Article history: Received 23 April 2016 Accepted 4 July 2016 Available online 9 July 2016 Background: Severe mitral stenosis is usually symptomatic and is treated by BMV or surgery, whereas mild to moderate mitral stenosis is usually asymptomatic or mildly symptomatic and managed medically. Patients in the later group may become symptomatic during episodes of exercise and increased heart rate. Beta-blockers are frequently used in patients with mitral stenosis to control the heart rate and alleviate exercise-related symp- toms. The objective of our study was to investigate the comparative efficacy of ivabradine versus metoprolol in patients with mitral stenosis in sinus rhythm. Methods: We studied 97 patients of mitral stenosis in sinus rhythm presented with exertional symptoms. The ef- fectiveness of Metoprolol was compared with ivabradine in alleviating these exertional symptoms in a random- ized, open label non crossover study. We also assessed various stress ECG parameters, 24 hour Holter parameters and 2D Echo parameters to objectively compare the effects of ivabradine and metoprolol in these patients. Results: Ivabradine and metoprolol both were effective in controlling exertional symptoms. Significant improve- ment in objective parameters like TMT (work capacity, baseline heart rate and maximal heart rate) and 2D echo- cardiography (right ventricular systolic pressure) are seen with both drugs. Ivabradine controls the exertional symptoms significantly more than metoprolol. On head to head comparison there was a significant benefit of working capacity and heart rate at maximal exercise in favour of ivabradine. Conclusions: Ivabradine should be strongly considered in medical management of mitral stenosis patients where beta blockers are contraindicated such as reactive airway disease. The cost of ivabradine is higher than metopro- lol which might possess constraints as most of the rheumatic heat disease patients belong to low socio economic status. © 2016 Elsevier Ireland Ltd. All rights reserved. Keywords: Exercise Mitral Stenosis 1. Introduction Rheumatic mitral stenosis is a common problem in the young popu- lation in most of the developing world [1]. Severe mitral stenosis is usu- ally symptomatic and is treated by balloon mitral valvuloplasty or surgery, whereas mild to moderate mitral stenosis is usually asymptom- atic or mildly symptomatic and managed medically [2]. Patients in the latter group may become symptomatic during episodes of exercise and increased heart rate. As increase in heart rate occurs mostly at the expense of diastole, there is shortening of the diastolic filling period, and in the presence of obstruction at the mitral valve this results in in- creased left atrial pressure. Subsequently, pulmonary capillary wedge pressure rises, resulting in effort intolerance and dyspnea [3]. Theoreti- cally, negative chronotropic agents such as beta-blockers and calcium channel blockers should be helpful in controlling tachycardia-related symptoms by improving diastolic filling and preventing rise in pulmo- nary capillary wedge pressure. However, associated negative inotropic effect on myocardium and effect on neuromuscular system may negate the beneficial effects of these drugs. Calcium channel blockers have little role in controlling heart rate when the patient is in sinus rhythm. Re- sults from various clinical and hemodynamic studies with these agents have been conflicting [4–6]. Ivabradine is a new negative chronotropic agent that has selective action on sinus rate by acting on the If current with no effect on myocar- dial contractility [7]. It has a better safety profile than beta-blockers, and various trials have reported very few side effects [8]. Pure heart rate re- duction with ivabradine, without any major cardiac or systemic effects, could be one of the reasons for better efficacy of this drug in improving effort tolerance. Ivabradine therefore seems to be an attractive option for heart rate reduction in patients with mitral stenosis in sinus rhythm. One study showed that ivabradine decreases resting heart rate and is as effective as metoprolol in increasing exercise duration, reducing transmitral International Journal of Cardiology 221 (2016) 562–566 ⁎ Corresponding author. E-mail address: vikky25@yahoo.com (V. Agrawal). http://dx.doi.org/10.1016/j.ijcard.2016.07.022 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard