Efficacy of trimetazidine on functional capacity in symptomatic patients with stable exertional angina — The VASCO-angina study

An updated review on therapeutic strategies in coronary microvascular dysfunction

Coronary microvascular dysfunction (CMD) is well-known cause of angina, yet treatment options remain limited. This systematic review and meta-analysis examines the current literature and provides a contemporary evaluation of treatments using a stringent definition for CMD with accurate methods of microvascular assessment in accordance with recent consensus guidelines. Methods and Results: A search strategy was conducted independently by two authors (CK and RR). Studies were required to be prospective trials in adult patients with documented CMD by IC doppler wire, thermodilution techniques, or perfusion imaging via PET/MRI. CMD was defined as either coronary flow reserve (CFR)/myocardial perfusion reserve (MPR) < 2.5, and/or index of microvascular resistance (IMR) > 25. Methodological quality of studies was assessed via the Cochrane Risk of Bias tool. The primary and secondary endpoints were change in CFR/MPR/IMR and change in Seattle Angina Questionnaire (SAQ) scores respectively. Two-sided p-values were used and considered significant if p < 0.05. A total of 11,360 records were identified, from which 14 were included in this review covering 9 different treatments. Two treatments (quinapril and ranolazine) showed significant improvement in both CFR and angina. Three ranolazine trials were pooled in meta-analysis. The standardised mean difference showed a weak positive effect (0.24) with wide intervals (-0.21 to 0.26) which was not statistically significant (p = 0.20). We subsequently reviewed all treatments as mentioned in recent European consensus statements. Conclusions: The overall quality of evidence surrounding treatments for CMD is of "low", with lack of robust data highlighting the dire need for higher quality trials in this area.

Efficacy and safety of yangxinshi versus trimetazidine on exercise tolerance in patients with coronary heart disease after percutaneous coronary intervention: Multicenter, double-blind clinical trial

BACKGROUND

Optimizing medication to improve exercise tolerance in patients with coronary heart disease (CHD) after percutaneous coronary intervention (PCI) is limited. Yangxinshi tablets, an herbal-based oral medicine, relieve symptoms of angina might be that they can improve energy metabolism of the ischemic myocardium. We conducted a randomized trial to assess the efficacy and safety of Yangxinshi vs. trimetazidine in improving exercise tolerance in patients with CHD after PCI.

METHODS

This prospective, randomized, double-blind, double-dummy, multicenter, non-inferiority study enrolled patients aged 18-75 years with CHD who underwent their first PCI within 2 months of diagnosis. Patients were randomized to Yangxinshi plus trimetazidine-placebo or trimetazidine plus Yangxinshi-placebo for 24 weeks. The primary endpoint was the change in metabolic equivalents (METs) assessed by cardiopulmonary exercise test (CPET) between 0 and 24 weeks. Secondary endpoints were comprehensive variables of the CPET, health status and adverse events. This study has been registered at ClinicalTrials. gov (NCT03809273).

RESULTS

Between August 1, 2019, and March 31, 2022, a total of 681 patients were randomized to Yangxinshi (n = 341) or trimetazidine (n = 340). After 24 weeks, the exercise tolerance of patients increased by 0.77±1.25 METs in the Yangxinshi group and 0.76±1.00 METs in the trimetazidine group (difference, 0.01; 95 % confidence interval [CI], -0.17 to 0.19), meeting the predefined non-inferiority threshold. Better outcomes were observed in the Yangxinshi group compared with the trimetazidine group for patient-reported depression (PHQ-9; -1.88±3.32 vs. -0.93±3.68; p < 0.001) and anxiety (GAD-7; -1.70±3.26 vs. -0.39±3.29; p < 0.001). Adverse events were similar in both groups.

CONCLUSIONS

In patients with CHD after PCI, Yangxinshi was non-inferior to trimetazidine in improving exercise tolerance during the 24-week treatment period. Notably, patients in the Yangxinshi group showed a better mental health profile compared with trimetazidine recipients.

Feasibility and application of trimetazidine in 18F-FDG PET myocardial metabolic imaging of diabetic mellitus patients with severe coronary artery disease: A prospective, self-controlled study

BACKGROUND

18F-FDG PET myocardial metabolic imaging (MMI) is sometimes uninterpretable due to background activity from uncontrolled glucose homeostasis in diabetic mellitus (DM) patients. Trimetazidine is an oral medication that promotes the transformation of myocardial energy supply from free fatty acids to glucose. We aimed to investigate the feasibility and application of trimetazidine in 18F-FDG PET MMI of DM patients.

METHODS

With DM patients exhibiting severe coronary artery disease (CAD) symptoms serving as self-controls, the effects of trimetazidine on PET MMI image quality, myocardial viability assessment, quantitative analytical parameters, and 18F-FDG uptake of different myocardial segments were elucidated.

RESULTS

The image quality of 18F-FDG MMI was graded visually as good, moderate, and uninterpretable. After trimetazidine, grades of good, moderate, and uninterpretable were observed in 14 (60.9%), 8 (34.8%), and 1 (4.3%) patients, respectively, and in 4 (17.4%), 15 (65.2%), 4 (17.4%) patients without trimetazidine. The myocardial SUV and myocardial to blood pool SUV ratio (M/B ratio) were significantly higher after trimetazidine administration than those before (3.11 ± 1.07 vs 2.32 ± 1.00, 2.67 ± 1.41 vs 1.81 ± 0.75, P all < 0.01). 6 (3, 7) viable myocardium segments were detected with a mismatch score of 10 (6, 17) after trimetazidine, significantly higher than those before trimetazidine [5 (2, 7) and 8 (2, 17), P < 0.05]. Meanwhile, the 18F-FDG uptake in myocardial segments with decreased and normal perfusion showed different ranges of increase (by 15.30%-57.77%).

CONCLUSION

Trimetazidine is feasible and effective in DM patients with severe CAD before 18F-FDG PET MMI, which can significantly improve the image quality and increase the number of viable myocardium segments detected.

TRIAL REGISTRY

The study was registered in the Chinese Clinical Trial Registry (ChiCTR2000038559).

Assessment of Trimetazidine Treatment in Acute Myocardial Infarction Patients Undergoing Percutaneous Coronary Intervention

Aims

Trimetazidine (TMZ) is effective at improving clinical outcomes in chronic heart failure and stable coronary artery disease patients. However, no single study has comprehensively evaluated the efficacy of TMZ in acute myocardial infarction (AMI) patients undergoing percutaneous coronary intervention (PCI).

Methods

We enrolled 401 Chinese patients. All patients received the same drug prescription except for TMZ. In blinded fashion, patients were randomized to either a control or an experimental group in which 60 mg TMZ was provided at admission and then at 20 mg three times a day thereafter. At 2 and/or 6 days, we evaluated creatine kinase (CK and CK-MB), cardiac troponin I (cTnI), C-reaction protein (CRP), serum tumor necrosis factor (TNF-α), serum creatinine (Cr), serum urea, glucose, glutamic pyruvic transaminase (ALT), and glutamic oxaloacetic transaminase (AST). Additionally, by echocardiography, we assessed left ventricular ejection fraction (LVEF), left ventricular end-diastolic dimension (LVEDD), and cardiac output (CO).

Results

CK and CKMB, which were recorded on the second day in the hospital (each p=0.022), and cTNI, which was recorded on the sixth day in the hospital (p=0.003), were reduced with TMZ treatment compared to control. In addition, ALT and AST (p=0.001, p=0.000, respectively) and glucose after 6 days (p=0.011) were significantly lower in the study group than in the control group. Furthermore, LVEF after 10–14 days and 6 months after discharge (p=0.039 and p=0.047, respectively) was increased with TMZ treatment. The effects of TMZ on CRP, TNF-α, Cr, urea, LVEDD, and CO were not significant (all p > 0.05).

Conclusions

For AMI patients undergoing PCI, TMZ reduced circulating biomarkers of myocardial infarction, reduced values of ALT, AST, and glucose, and improved cardiac function compared with the control group.

S-15176 Difumarate Salt Can Impair Mitochondrial Function through Inhibition of the Respiratory Complex III and Permeabilization of the Inner Mitochondrial Membrane

S-15176 difumarate salt, a derivative of the anti-ischemic metabolic drug trimetazidine, has been intensively studied for its impact on cellular metabolism in animal models of ischemia-reperfusion injury of the liver, heart, spinal cord, and other organs. Despite evidence of some reduction in oxidative damage to cells, the results of therapy with S-15176 have been mostly disappointing, possibly because of the lack of data on its underlying mechanisms. Here, we aimed to investigate in more detail the role of complexes I-IV of the electron transport chain and membrane permeability transition in mitochondrial toxicity associated with S-15176. Using rat thymocyte and liver mitochondria, we demonstrated that: (1) acute exposure to S-15176 (10 to 50 μM) dose-dependently decreased the mitochondrial membrane potential; (2) S-15176 suppressed the ADP-stimulated (State 3) and uncoupled (State 3UDNP) respiration of mitochondria energized with succinate or malate/glutamate, but not ascorbate/TMPD, and increased the resting respiration (State 4) when using all the substrate combinations; (3) S-15176 directly inhibited the activity of the respiratory complex III; (4) low doses of S-15176 diminished the rate of H2O2 production by mitochondria; (5) at concentrations of above 30 μM, S-15176 reduced calcium retention capacity and contributed to mitochondrial membrane permeabilization. Taken together, these findings suggest that S-15176 at tissue concentrations reached in animals can impair mitochondrial function through suppression of the cytochrome bc1 complex and an increase in the nonspecific membrane permeability.

ACPTI study: Being positive in a negative situation is not naivety - Trimetazidine still has role in symptomatic CAD patients

RESULTS

of the efficAcy and safety of Trimetazidine in patients with angina pectoris having been treated by Percutaneous Coronary Intervention (ATPCI) study showed no significant difference in the incidence of primary endpoint events between trimetazidine and placebo group in angina patients who recently underwent percutaneous coronary intervention. However, the study had limitations specific to both, design and selection of patient population. Here, we present some explanations for the null effects of trimetazidine in the ATPCI study and their relevance in routine clinical practice.

Effects of trimetazidine on ventricular remodeling in coronary artery disease patients with left ventricular hypertrophy: the rationale and design of a randomized controlled trial

Background

Trimetazidine is a metabolic anti-ischemic agent, which increases the tolerance of cardiomyocytes to ischemia. However, few studies have explored the effect of trimetazidine on ventricular remodeling in coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI) with left ventricular hypertrophy (LVH).

Methods

It is a randomized, placebo-controlled trial, and we propose to recruit one hundred and twenty-four CAD patients undergoing PCI with LVH during a 12-month period. They will be randomized to receive either trimetazidine (35 mg twice a day) or placebo in the following 12 months after PCI. Blood tests, echocardiography, symptom of angina and major adverse cardiovascular events (MACEs) will be collected at follow-up visit at 3 and 12 months. The primary end point will be the left ventricular remodeling measured by left ventricular mass index (LVMI) at 3- and 12-month follow-up compared with the baseline. The secondary end points will be the symptom of angina assessed by Seattle Angina Questionnaire, myocardial ischemia measured by 6-min walk test and exercise electrocardiography test, as well as MACEs (defined as a composite of death, myocardial infarction, stroke, recurrent angina, re-hospitalization, change of viable myocardium).

Discussion

This study aims to demonstrate the effect of trimetazidine on left ventricular remodeling and myocardial ischemia in CAD patients undergoing PCI with LVH. Trimetazidine treatment is likely to improve the left ventricular remodeling, symptoms of angina and myocardial ischemia. It might also reduce the risk of MACEs in CAD patients undergoing PCI with LVH.

Trial registration

http://www.chictr.org.cn, Chinese Clinical Trial Registry (ChiCTR1800017876). Registered on 19 Aug 2018.

Evidence in Guidelines for Treatment of Coronary Artery Disease

In this chapter, we focus on evidences in current guidelines for treatment of coronary artery disease (CAD). In Part 1, diet and lifestyle management is discussed, which plays an important role in CAD risk control, including forming healthy dietary pattern, maintaining proper body weight, physical exercise, smoking cessation, and so on. Part 2 elaborated on revascularization strategies and medical treatments in patients presenting with acute coronary syndrome (ACS), including specific AHA and ESC guidelines on ST elevation myocardial infarction (STEMI) and non-ST elevation ACS (NSTE-ACS). Part 3 discussed chronic stable coronary artery disease (SCAD), the treatment objective of which is a combination of both symptomatic and prognostic improvement. Yet many of the recommendations for SCAD are expert-based rather than evidence-based. Initial medical treatment is safe and beneficial for most patients. While cumulating studies have focused on optimizing pharmacological therapy (referring to nitrates, beta-blockers, calcium channel blockers, antiplatelet agents, ACEI/ARB, statins, etc.), education, habitual modification, and social support matters a lot for reducing cardiac morbidity and mortality. Patients with moderate-to-severe symptoms and complex lesions should be considered for revascularization. But practical management of revascularization shall take individual characteristics, preference, and compliance into consideration as well.

Mitochondrial function in the heart: the insight into mechanisms and therapeutic potentials

Mitochondrial dysfunction is considered as a crucial contributory factor in cardiac pathology. This has highlighted the therapeutic potential of targeting mitochondria to prevent or treat cardiac disease. Mitochondrial dysfunction is associated with aberrant electron transport chain activity, reduced ATP production, an abnormal shift in metabolic substrates, ROS overproduction and impaired mitochondrial dynamics. This review will cover the mitochondrial functions and how they are altered in various disease conditions. Furthermore, the mechanisms that lead to mitochondrial defects and the protective mechanisms that prevent mitochondrial damage will be discussed. Finally, potential mitochondrial targets for novel therapeutic intervention will be explored. We will highlight the development of small molecules that target mitochondria from different perspectives and their current progress in clinical trials. LINKED ARTICLES: This article is part of a themed section on Mitochondrial Pharmacology: Featured Mechanisms and Approaches for Therapy Translation. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.22/issuetoc.

[Effect of trimetazidine on cardiac function and exercise tolerance in hypertension patients with diabetic]

OBJECTIVE

To determine the effect of trimetazidine on cardiac function and exercise tolerance in primary hypertension patients with type 2 diabetic.

METHODS

In this randomized, double-blind, placebo-controlled prospective study, 60 primary hypertensive patients with diabetic were equally assigned into two groups, patients received trimetazidine (20 mg, 3 times a day) or placebo for 1 year. Echocardiography, cardiopulmonary exercise testing were performed; and the plasma N terminal pro B type natriuretic peptide (NT-ProBNP), hr-CRP, TNF-α, angiotensin Ⅱ and endothelin concentration were determined before and after treatment.

RESULTS

In trimetazidine group, the left ventricular mass index, the mitral flow velocity E wave to A wave ratio (E/A), the peak early diastolic velocity (V_E) to late diastolic velocity (V_A) ratio (V_E/V_A) and the peak systolic velocity (Vs) were significantly improved, the plasma NT-ProBNP level was significantly decreased, and the exercise time, metabolic equivalent, maximal oxygen uptake and anaerobic threshold were significantly increased (all P<0.05); plasma concentration of hr-CRP, TNF-α, angiotensin Ⅱ and endothelin were significantly reduced after trimetazidine treatment, compared with baseline (all P<0.05) and with placebo (all P<0.05). There were no significant differences in any of above parameters after treatment in placebo group (all P>0.05). No severe adverse reaction was observed in both groups.

CONCLUSIONS

For patients with both hypertension and diabetes, trimetazidine can improve cardiac function and increase exercise tolerance.

A Retrospective Study of Hemodynamic Changes in Patients After Off-Pump Coronary Artery Bypass Graft Surgery Using Impedance Cardiography

Background

This study aimed to investigate the role of impedance cardiography (ICG) to evaluate hemodynamic changes in patients after off-pump coronary artery bypass graft (OPCABG) surgery.

Material/Methods

One-hundred and sixty patients who had undergone OPCAGB were enrolled and assessed using New York Heart Association NYHA functional class (II, II, and IV). ICG was used to measure the stroke volume (SV), stroke volume index (SI), cardiac output per minute (CO/min), cardiac index (CI), end-diastolic volume (EDV), pre-ejection period (PEP), left ventricular ejection time (LVET), systolic time ratio (STR), left ventricular ejection fraction (LVEF), acceleration index (ACI), systemic vascular resistance (SVR), and thoracic fluid content (TFC). The ICG parameters were correlated with brain natriuretic peptide (BNP) and echocardiography parameters using multivariate regression analysis.

Results

The levels of CO, ACI, TFC, SVR, and BNP compared with ICG showed differences between NYHA functional class, with CO showing a significant difference (p<0.05). There were no significant differences between SV, SI, EDV, and LVEF before and after OPCAGB. Using ICG, the parameters of CI, LVEF, EDV, and TFC showed no significant correlation with BNP. SV, SI, CO, ACI, and LVET, which were negatively correlated with BNP. SVR, PEP, and STR were positively correlated with BNP (P<0.05).

Conclusions

In patients who had OPCABG, the findings from ICG were significantly correlated with BNP levels and the results from echocardiography for the evaluation of cardiac hemodynamic changes. ICG might have a role in the assessment of cardiac function in clinical practice.

Trimetazidine in the Prevention of Tissue Ischemic Conditions

Trimetazidine (TMZ) is a metabolic agent with significant anti-ischemic properties. By inhibiting the terminal enzyme in the β-oxidation pathway, it shifts the energy substrate metabolism, enhancing glucose metabolism. Thus, it maintains the required energy production with less oxygen consumption, an effect necessary in cases of myocardi. Trimetazidine was recently reaccredited as add-on therapy for symptomatic treatment in patients with stable angina, not adequately controlled or intolerant to first-line therapy. Trimetazidine was included in the European Society of Cardioloy 2013 guidelines for the management of stable coronary artery disease. Although TMZ has been used in cardiology for >40 years, only a few studies have assessed its effects in patients with acute ischemic conditions. This review summarizes the current literature regarding the addition of TMZ in patients with acute ischemic conditions (acute myocardial infarction, ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, percutaneous coronary intervention, and coronary artery bypass grafting). There is growing evidence from recent studies that the addition of TMZ in patients with such conditions is beneficial in terms of myocardial damage and major cardiac events as well as decreasing reperfusion injury and contrast-induced nephropathy.

Trimetazidine combined with berberine on endothelial function of patients with coronary heart disease combined with primary hypertension

Effects of trimetazidine combined with berberine on endothelial function of patients with coronary heart disease combined with primary hypertension (CCP) were investigated. A total of 68 patients with CCP were selected from July 2014 to August 2016 to serve as observation group. At the same time, 68 healthy people were also selected to serve as control group (physiological saline). Expression of endothelial nitric oxide synthase (eNOS) mRNA in the blood samples of the observation and control groups before and after treatment was determined by RT-PCR. Levels of NO in the plasma of the observation and control groups before and after treatment were measured by nitric acid reductase method. Brachial artery flow-mediated vasodilation (FMD) of observation and control groups was detected by brachial artery ultrasonography before and after treatment. Before treatment, expression level of eNOS mRNA in blood of the observation group was significantly lower than that of the control group (P<0.05). After treatment, expression level of eNOS mRNA was significantly increased (P<0.05). Plasma NO content 41.06±3.63 mol/l in blood of the observation group was significantly lower than that of the control group 53.28±3.09 mol/l (P<0.05). After treatment with trimetazidine and berberine, level of NO 50.75±2.75 mol/l was significantly increased compared with the level before treatment (P<0.05). FMD value (5.03±0.95) was significantly lower in observation group than that in control group (16.04±1.63) (P<0.05). After treatment with trimetazidine and berberine, FMD value (14.02±2.39) was significantly increased compared with the level before treatment (P<0.05). The results suggested that the combination of trimetazidine and berberine can increase the content of NO in blood and promote endothelium-dependent dilation function of brachial arteries, which is helpful in the treatment of CCP.

Trimetazidine and Other Metabolic Modifiers

Treatment goals for people with chronic angina should focus on the relief of symptoms and improving mortality rates so the patient can feel better and live longer. The traditional haemodynamic approach to ischaemic heart disease was based on the assumption that increasing oxygen supply and decreasing oxygen demand would improve symptoms. However, data from clinical trials, show that about one third of people continue to have angina despite a successful percutaneous coronary intervention and medical therapy. Moreover, several trials on chronic stable angina therapy and revascularisation have failed to show benefits in terms of primary outcome (survival, cardiovascular death, all-cause mortality), symptom relief or echocardiographic parameters. Failure to significantly improve quality of life and prognosis may be attributed in part to a limited understanding of ischaemic heart disease, by neglecting the fact that ischaemia is a metabolic disorder. Shifting cardiac metabolism from free fatty acids towards glucose is a promising approach for the treatment of patients with stable angina, independent of the underlying disease (macrovascular and/or microvascular disease). Cardiac metabolic modulators open the way to a greater understanding of ischaemic heart disease and its common clinical manifestations as an energetic disorder rather than an imbalance between the demand and supply of oxygen and metabolites.

Effectiveness and safety of anti-ischemic trimetazidine in patients with stable angina pectoris and Type 2 diabetes

Aim & methods: This 6-month prospective, observational, noninterventional, open-label clinical study assessed the effectiveness/safety of trimetazidine in 737 patients with stable angina pectoris and Type 2 diabetes mellitus (OGYI/51534–1/2014). Results: Trimetazidine-based therapy was effective in stable coronary artery disease, with significant improvements from baseline (p < 0.05) in: number of angina attacks/week (2.9 ± 2.4 vs 1.1 ± 1.6), angina severity (Canadian Cardiovascular Society Classification 1.9 ± 0.8 vs 1.2 ± 0.8), exercise capacity (metabolic equivalents 6.1 ± 1.7 vs 6.5 ± 1.7), and exercise-induced myocardial ischemia (min 5.5 ± 2.5 vs 6.5 ± 2.6). Discussion: Trimetazidine treatment significantly (p < 0.05) improved glucose metabolism, lowered HbA1c (7.1 ± 1.1% vs 6.6 ± 1.0%), glucose levels (7.7 ± 2.1 mmol/l vs 6.9 ± 1.6 mmol/l) and decreased arterial stiffness (pulse wave velocity 11.2 ± 2.1 m/s vs 10.4 ± 2.2 m/s). In most patients, the tolerability of trimetazidine was rated as excellent to good, with a low incidence of adverse events.

Modulation of myocardial energetics: An important category of agents in the multimodal treatment of coronary artery disease and heart failure

The combined and relative contribution of glucose and fatty acid oxidation generates myocardial energy, which regulates the cardiac function and efficiency. Any dysregulation in this metabolic homeostasis can adversely affect the function of heart and contribute to cardiac conditions such as angina and heart failure. Metabolic agents ameliorate this internal metabolic anomaly, by shifting the energy production pathway from free fatty acids to glucose, resulting in a better performance of the heart. Metabolic therapy is relatively a new modality, which functions through optimization of cardiac substrate metabolism. Among the metabolic therapies, trimetazidine and ranolazine are the agents presently available in India. In the present review, we would like to present the metabolic perspective of pathophysiology of coronary artery disease and heart failure, and metabolic therapy by using trimetazidine and ranolazine.

Real-world Evidence for the Antianginal Efficacy of Trimetazidine from the Russian Observational CHOICE-2 Study

INTRODUCTION

The guidelines recommend a beta-blocker or calcium channel blocker as the first-line medication for angina, supplemented by other agents for additional symptoms. One such agent is trimetazidine (TMZ), which has been shown to reduce the frequency of anginal episodes and improve exercise performance without affecting haemodynamic parameters. However, extensive real-world evidence for its efficacy in combination with first-line therapies has been lacking.

METHODS

The aim of this large-scale, Russian, multicentre, 6-month, open-label, prospective observational study was to assess the effect of adding TMZ modified release 35 mg bid to background antianginal therapy in the real-world clinical setting.

RESULTS

The study included 896 patients: 54% women, aged 29-90 years (42.6% >65 years), 63% with class II angina, and receiving beta-blockers alone or in combination (93%). Add-on TMZ reduced angina frequency and short-acting nitrate use within 2 weeks (both p < 0.0001) regardless of background therapy and maintained this effect over 6 months. It increased the proportion of patients with class I angina sixfold while decreasing that of class 3 angina almost fourfold. It also improved walking distance and well-being at 6 months (both p < 0.0001). Treatment was well tolerated.

CONCLUSION

Add-on TMZ is a safe and rapidly effective treatment for reducing angina attacks and nitrate use in the real-world clinical setting. It also increases exercise capacity and well-being. These effects are observed within 2 weeks and persist for at least 6 months.

[Triple antianginal combinations in the treatment of elderly and senile patients with stable angina]

AIM

To compare the efficiency and safety of antianginal therapy (AAT) using a combination of bisoprolol, ivabradine, and trimetazidine or ranolazine in elderly and senile patients with stable angina.

SUBJECTS AND METHODS

The study enrolled 107 patients aged 60 to 79 years with coronary heart disease and Functional Class II and III angina. When the patients taking bisoprolol 1.25-2.5 mg once daily and ivabradine 2.5-7.5 mg twice daily continued to have angina and/or silent myocardial ischemia, after randomization 54 patients received an additional 35 mg of trimetazidine twice a day and 53 patients had ranolazine 500 mg twice daily. A comprehensive clinical and instrumental study was conducted prior to randomization and after 6 months of triple AAT.

RESULTS

The patients tolerated well both treatments that substantially improved the results of a treadmill exercise test. Trimetazidine reduced to a greater extent the duration of silent ST-segment depression, as evidenced by Holter monitoring. Trimetazidine and ranolazine comparably improved left ventricular systolic and diastolic function, large arterial structure and function, and quality of life in the patients.

CONCLUSION

The combinations of the low-dose β-blocker with ivabradine and trimetazidine or ranolazine may be used to treat refractory stable angina in elderly and senile patients. Trimetazidine is preferred due to its higher efficacy in treating silent myocardial ischemia and to its lower cost.

Management standards for stable coronary artery disease in India

Coronary artery disease (CAD) is one of the important causes of cardiovascular morbidity and mortality globally, giving rise to more than 7 million deaths annually. An increasing burden of CAD in India is a major cause of concern with angina being the leading manifestation. Stable coronary artery disease (SCAD) is characterised by episodes of transient central chest pain (angina pectoris), often triggered by exercise, emotion or other forms of stress, generally triggered by a reversible mismatch between myocardial oxygen demand and supply resulting in myocardial ischemia or hypoxia. A stabilised, frequently asymptomatic phase following an acute coronary syndrome (ACS) is also classified as SCAD. This definition of SCAD also encompasses vasospastic and microvascular angina under the common umbrella.

The risk of cardiovascular side effects with anti-anginal drugs

INTRODUCTION

Angina pectoris is a common presenting symptom of underlying coronary artery disease or reduced coronary flow reserve. Patients with angina have impaired quality of life; and need to be treated optimally with antianginal drugs to control symptoms and improve exercise performance. A wide range of antianginal medications are approved for the treatment of angina, and often more than one class of antianginal drugs are used to adequately control the symptoms. This expert opinion highlights the likely cardiac adverse effects of available antianginal drugs, and how to minimize these in individual patients and especially during combination treatment. Areas covered: All approved antianginal drugs, including the older and newly approved medications with different mechanism of action to the older drugs as well as some of the unapproved herbal medications. The safety profiles and potential cardiac side effects of these medications when used as monotherapy or as combination therapy are discussed and highlighted. Expert opinion: Because of the different cardiac safety profiles and possible side effects, we recommend selection of initial drug or adjustment of therapy based on the resting heart rate; blood pressure, hemodynamic status; and resting left ventricular function, concomitant medications and any associated comorbidities.

Economic evaluation of trimetazidine in the management of chronic stable angina in Greece

Background

To evaluate the cost-effectiveness of trimetazidine (TMZ) as add-on therapy to standard-of-care (SoC) compared to SoC alone in patients with chronic stable angina who did not respond adequately to first line therapy with b-blockers, nitrates or calcium channel antagonists in Greece.

Methods

A Markov model with 3-month cycles and 1-year time horizon was developed to assess the comparators. The analysis was conducted from a third-party payer perspective. The clinical inputs and utility values were extracted from the published literature. Resource consumption data were obtained from local experts, using a questionnaire developed for the purpose of the study and were combined with unit cost data (in €2016) obtained from official sources. Cost effectiveness was assessed by calculating the incremental cost effectiveness ratio (ICER). Probabilistic sensitivity analysis (PSA) was performed to account for uncertainty and variation in the input parameters of the model.

Results

The analysis showed that the cost of TMZ plus SoC was €1755.57 versus €1751.76 of SoC alone. In terms of health outcomes, TMZ plus SoC was associated with 0.6650 QALYs versus 0.6562 QALYs for SoC alone. The incremental analysis resulted in an ICER of €430.67 per QALY gained. PSA revealed that the probability of TMZ plus SoC being cost-effective over SoC was 89 %, at a threshold of €34,000 per QALY gained.

Conclusion

The results indicate that TMZ as add –on treatment may be a highly cost-effective option for the symptomatic treatment of patients with chronic stable angina in Greece relative to SoC alone.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1779-6) contains supplementary material, which is available to authorized users.

Trimetazidine does not alter metabolic substrate oxidation in cardiac mitochondria of target patient population

BACKGROUND AND PURPOSE

Trimetazidine, known as a metabolic modulator, is an anti-anginal drug used for treatment of stable coronary artery disease (CAD). It is proposed to act via modulation of cardiac metabolism, shifting the mitochondrial substrate utilization towards carbohydrates, thus increasing the efficiency of ATP production. This mechanism was recently challenged; however, these studies used indirect approaches and animal models, which made their conclusions questionable. The goal of the current study was to assess the effect of trimetazidine on mitochondrial substrate oxidation directly in left ventricular myocardium from CAD patients.

EXPERIMENTAL APPROACH

Mitochondrial fatty acid (palmitoylcarnitine) and carbohydrate (pyruvate) oxidation were measured in permeabilized left ventricular fibres obtained during coronary artery bypass grafting surgery from CAD patients, which either had trimetazidine included in their therapy (TMZ group) or not (Control).

KEY RESULTS

There was no difference between the two groups in the oxidation of either palmitoylcarnitine or pyruvate, and in the ratio of carbohydrate to fatty acid oxidation. Activity and expression of pyruvate dehydrogenase, the key regulator of carbohydrate metabolism, were also not different. Lastly, acute in vitro exposure of myocardial tissue to different concentrations of trimetazidine did not affect myocardial oxidation of fatty acid.

CONCLUSION AND IMPLICATIONS

Using myocardial tissue from CAD patients, we found that trimetazidine (applied chronically in vivo or acutely in vitro) had no effect on cardiac fatty acid and carbohydrate oxidation, suggesting that the clinical effects of trimetazidine are unlikely to be due to its metabolic effects, but rather to an as yet unidentified intracardiac mechanism.

Defining the role of trimetazidine in the treatment of cardiovascular disorders: some insights on its role in heart failure and peripheral artery disease

Trimetazidine is a cytoprotective drug whose cardiovascular effectiveness, especially in patients with stable ischemic heart disease, has been the source of much controversy in recent years; some have gone so far as to treat the medication as a ‘placebo drug’ whose new side effects, such as Parkinsonian symptoms, outweigh its benefits. This article is an attempt to present the recent key studies, including meta-analyses, on the use of trimetazidine in chronic heart failure, also in patients with diabetes mellitus and arrhythmia, as well as in peripheral artery disease. This paper also includes the most recent European Society of Cardiology guidelines, including those of 2013, on the use of trimetazidine in cardiovascular disease.

The effect of trimetazidine added to pharmacological treatment on all-cause mortality in patients with systolic heart failure

The anti-ischemic agent trimetazidine (TMZ) added to pharmacological treatment appears to have positive effects on cardiac parameters of patients with heart failure (HF) as a result of specific antioxidant properties.

OBJECTIVES

We aimed to verify whether the marked improvement provided by TMZ in echocardiographic and clinical parameters was likely to translate into reduced all-cause mortality in systolic HF patients.

METHODS

Meta-analysis of available published prospective randomized controlled trial (RCT) data (1967-2014) retrieved from PubMed, Web of Science and Cochrane Collaboration.

RESULTS

A total of 326 patients from 3 RCTs were analyzed: 164 who received TMZ on top of pharmacological HF therapy and 162 controls. Study durations ranged from 12 to 48 months. The analysis had no publication bias and the studies were homogeneous (p = 0.442, I(2) = 0). The results show a significant effect of TMZ on the reduction of all-cause mortality (RR = 0.283, p < 0.0001). The rate of events attributable to the drug was lower with TMZ than it was among control patients.

CONCLUSION

This meta-analysis suggests that in patients with HF, TMZ given as an add-on therapy is likely to provide a protective effect, reduce all-cause mortality and increase event-free survival, and could be an effective and useful adjunct to our armamentarium for the treatment of HF patients.

Trimetazidine and cardioprotection: facts and perspectives

Trimetazidine (TMZ) is a metabolic agent used in cardiology for more than 40 years. Several studies assessed the cardioprotective effects of TMZ in patients with chronic coronary heart disease (CHD) as well as in patients with heart failure (HF). In light of the inclusion of TMZ in the current guidelines on the management of stable CHD, we reviewed the published literature on TMZ, focusing mainly its effects on patients with stable angina and HF. According to the published literature, there is sufficient evidence to support the addition of this agent in the treatment of symptomatic patients with stable angina.