The BEAUTIFUL (morBidity-mortality EvAlUaTion of the If inhibitor ivabradine in 
patients with coronary artery disease and left ventricULar systolic dysfunction) 
study assessed the morbidity and mortality benefits of the HR-lowering agent 
ivabradine. The placebo arm of the BEAUTIFUL trial was a large cohort of 
patients with stable coronary artery disease (CAD) and left ventricular systolic 
dysfunction. A subanalysis in the placebo group tested the hypothesis that 
elevated resting HR at baseline was a marker for subsequent cardiovascular death 
and morbidity. The primary aim of the study was to test whether lowering the HR 
with ivabradine reduced cardiovascular death and morbidity in patients with CAD 
and left ventricular systolic dysfunction. In the overall analysis, reduction in 
HR with ivabradine did not improve cardiac outcomes compared with placebo. The 
most important finding of the study was that patients with high baseline HR had 
an increase in serious cardiovascular events including death (34%), hospital 
admission secondary to congestive heart failure (53%), acute myocardial 
infarction (46%), or revascularization procedure (38%). In addition, in the 
subset analysis focusing on patients with baseline HR > or =70 bpm and left 
ventricular ejection fraction <40% the agent resulted in a 36% decrease in 
hospital admissions secondary to fatal and nonfatal myocardial infarction and a 
30% decrease in coronary revascularization. The first practical implication from 
the study includes that baseline HR should be recorded in addition to other risk 
factors such as BP and lipid profile, in the follow-up of patients with CAD. 
Attempts should be made to achieve HR <70 bpm by cardiac rehabilitation and 
routine use of appropriately dosed beta-blockers. Despite the neutral results 
obtained in the BEAUTIFUL study, ivabradine could be administered to the 
subgroup of patients in whom HR <70 bpm is not achieved despite proper dosing of 
beta-blockers and in those in whom beta-blockers are contraindicated. 
Furthermore, in clinical practice, ivabradine may be helpful for patients with 
stable CAD who have a high HR while receiving beta-blockers. Future studies are 
needed to confirm the hypothesis that single reduction of HR can improve 
cardiovascular prognosis.