Initiation of ivabradine in cardiogenic shock

Ivabradine is a selective sinus node inhibitor indicated in patients with symptomatic chronic heart failure on stable guideline‐recommended heart failure therapy including appropriate doses of beta‐blockers. The use in cardiogenic shock remains off label and has been considered a contraindication due to the theoretical risk of attenuating compensatory tachycardia. Tachycardia, especially in the context of inotropic therapy, may be deleterious, resulting in increased myocardial oxygen consumption and reduction in diastolic filling. As ivabradine does not have negative inotropic action, it may present a potential means to manage tachycardia in cardiogenic shock. We present a case series of four patients with cardiogenic shock started on ivabradine who were unable to tolerate beta‐blockers.