Trimetazidine: is there a role beyond angina?

High-fat stimulation induces atrial neural remodeling by reducing NO production via the CRIF1/eNOS/P21 axi

BACKGROUND

Autonomic remodeling of the atria plays a pivotal role in the development of atrial fibrillation (AF) and exerts a substantial influence on the progression of this condition. Hyperlipidemia is a predisposing factor for AF, but its effect on atrial nerve remodeling is unclear. The primary goal of this study was to explore the possible mechanisms through which the consumption of a high-fat diet (HFD) induces remodeling of atrial nerves, and to identify novel targets for clinical intervention.

METHODS

Cell models were created in vitro by subjecting cells to palmitic acid (PA), while rat models were established by feeding them a high-fat diet. To investigate the interplay between cardiomyocytes and nerve cells in a co-culture system, we utilized Transwell cell culture plates featuring a pore size of 0.4 μm. The CCK-8 assay was employed to determine cell viability, fluorescent probe DCFH-DA and flow cytometry were utilized for measuring ROS levels, JC-1 was used to assess the mitochondrial membrane potential, the Griess method was employed to measure the nitric oxide (NO) level in the supernatant, a fluorescence-based method was used to measure ATP levels, and MitoTracker was utilized for assessing mitochondrial morphology. The expression of pertinent proteins was evaluated using western blotting (WB) and immunohistochemistry techniques. SNAP was used to treat nerve cells in order to replicate a high-NO atmosphere, and the level of nitroso was assessed using the iodoTMT reagent labeling method.

RESULTS

The study found that cardiomyocytes' mitochondrial morphology and function were impaired under high-fat stimulation, affecting nitric oxide (NO) production through the CRIF1/SIRT1/eNOS axis. In a coculture model, overexpression of eNOS in cardiomyocytes increased NO expression. Moreover, the increased Keap1 nitrosylation within neuronal cells facilitated the entry of Nrf2 into the nucleus, resulting in an augmentation of P21 transcription and a suppression of proliferation. Atrial neural remodeling occurred in the HFD rat model and was ameliorated by increasing myocardial tissue eNOS protein expression with trimetazidine (TMZ).

CONCLUSIONS

Neural remodeling is triggered by high-fat stimulation, which decreases the production of NO through the CRIF1/eNOS/P21 axis. Additionally, TMZ prevents neural remodeling and reduces the occurrence of AF by enhancing eNOS expression.

Bioequivalence and Pharmacokinetic Profiles of 2 Trimetazidine Modified-release Tablets Under Fasting and Fed Conditions in Chinese Healthy Subjects

This study aims to assess the bioequivalence of test and reference formulations of trimetazidine dihydrochloride in healthy Chinese volunteers under fasting and fed conditions, and to determine the effect of food on the pharmacokinetic profiles of both formulations. A randomized, open-label, crossover, four-period study with a 7-day washout period was conducted in 24 healthy Chinese subjects. The subjects fasted for at least 10 hours before being given a single 35-mg dose of the test and reference tablets. Venous blood samples were taken from predose at 0 hours to postdose at 36 hours at scheduled time points. The main pharmacokinetic parameters were calculated with a noncompartmental model. The nonparametric test of T_max under both conditions showed no significant difference between the two formulations (P > .05). The 90% confidence intervals of geometric mean ratio of lnC_max and lnAUC_0→∞ (the logarithmic values of area under the plasma concentration-time curve [AUC] and mean maximum plasma concentration [C_max ]) all fell within 80%-125%. C_max in the fed state was slightly higher than that in the fasting state (P < .05), while other pharmacokinetic parameters were comparable. No severe adverse events occurred. The test and reference formulations were bioequivalent under both fasting and fed conditions. Food did not affect the pharmacokinetic profiles of trimetazidine in Chinese healthy volunteers, therefore trimetazidine is suitable for administration under fasting or fed conditions.

Predictors of restenosis following percutaneous coronary stent implantation: The role of trimetazidine therapy

Aims

In-stent restenosis (ISR) is an unresolved problem following percutaneous coronary intervention (PCI), having a negative impact on clinical outcome. The main goal of this study was to find new independent predictors that may influence the development of ISR.

Methods and results

In this retrospective analysis, 653 PCI patients were involved. All patients had coronary stent implantation and a follow-up coronary angiography. Based on the presence of ISR at follow-up, patients were divided into two groups: 221 in the ISR and 432 in the control group. When evaluating the medical therapy of patients, significantly more patients were on trimetazidine (TMZ) in the control compared to the ISR group (p = 0.039). TMZ was found to be an independent predictor of a lower degree of ISR development (p = 0.007). TMZ treatment was especially effective in bare metal stent (BMS)-implanted chronic coronary syndrome (CCS) patients with narrow coronary arteries. The inflammation marker neutrophil to lymphocyte ratio (NLR) was significantly elevated at baseline in the ISR group compared to controls. The reduction of post-PCI NLR was associated with improved efficacy of TMZ to prevent ISR development. Drug eluting stent implantation (p < 0.001) and increased stent diameter (p < 0.001) were the most important independent predictors of a lower degree of ISR development, while the use of longer stents (p = 0.005) was a major independent predictor of an increased ISR risk.

Conclusion

TMZ reduces the occurrence of ISR following PCI, with special effectiveness in BMS-implanted patients having CCS and narrow coronary arteries. TMZ treatment may help to lower ISR formation in countries with high BMS utilization rates.

Trimetazidine offers myocardial protection in elderly coronary artery disease patients undergoing non-cardiac surgery: a randomized, double-blind, placebo-controlled trial

Background

Trimetazidine (TMZ) pretreatment protects cardiomyocytes during cardiac surgery. TMZ may protect elderly patients with ischaemic heart disease (IHD) undergoing non-cardiac surgery.

Methods

This was a randomized, double-blind, placebo-controlled trial (registration #ChiCTR1900025018) of patients with IHD scheduled to undergo non-cardiac surgery at Shenzhen People’s Hospital (Shenzhen, Guangdong Province, China) between June 2014 and September 2015, randomized to 60 mg TMZ or placebo 12 h before surgery. The primary endpoint was the occurrence of in-hospital cardiovascular events. The secondary endpoints were myocardial ischaemia on five-lead electrocardiogram (cECG), cardiac troponin I (cTnI) elevation, cardiac death, acute coronary events, heart failure, and arrhythmia requiring treatments.

Results

Compared with the placebo group, the TMZ group showed a lower occurrence of in-hospital cardiovascular events (primary endpoint, 20.0% vs. 37.5%, P = 0.02), myocardial ischaemia (15.0% vs. 32.5%, P < 0.01), cTnI elevation (2.5% vs. 10%, P < 0.01), acute coronary events (10.0% vs. 20.0%, P < 0.05), heart failure (0% vs. 2.5%, P < 0.05), and arrhythmia requiring treatment (17.5% vs. 35.0%, P < 0.05). There was no acute myocardial infarction during the 30-day postoperative period.

Conclusions

In elderly patients with IHD undergoing non-cardiac surgery, TMZ pretreatment was associated with myocardial protective effects.

Trial registration The trial was prospectively registered at http://www.chictr.org.cn/showproj.aspx?proj=41909 with registration number [ChiCTR1900025018] (7/8/2019).

Trimetazidine Use in Parkinson's Disease: Is It a Resolved Problem?

Trimetazidine (TMZ), an antianginal drug, can worsen the symptoms of movement disorders, therefore, the European Medicines Agency (EMA) recommended avoiding the use of this drug in Parkinson’s disease (PD). We investigated the impact of this recommendation on the observed trend of TMZ use in PD in Hungary from 2010 to 2016 by conducting a nationwide, retrospective study of health administrative data of human subjects. Interrupted time series analyses were performed to explore changes in user trends after the EMA recommendations. We found that TMZ use in PD decreased by 6.56% in each six-month interval after the EMA intervention [a change in trend of −530.22, 95% confidence interval (CI) = −645.00 to −415.44, p < 0.001 and a decrease in level of −567.26, 95% CI = −910.99 to −223.53, p = 0.005 12 months postintervention]. TMZ discontinuation was the highest immediately after the intervention, however, its rate slowed down subsequently (a change in trend of −49.69, 95% CI = −85.14 to −14.24, p = 0.11 without significant level effects). The rate of new TMZ prescriptions did not reduce significantly, therefore, the decreased overall use was mainly attributable to the increased rate of discontinuation only. The main indications for TMZ use were circulatory system disorders, especially angina pectoris, however, off-label utilization was also considerable (40%). The EMA recommendations on TMZ use seem to be only moderately effective in Hungary. Although the number of patients with PD on the drug modestly decreased after the EMA restrictions, TMZ is still widely used in PD for both on-label and off-label indications.

Trimetazidine in Heart Failure

Heart failure is a systemic syndrome caused by multiple pathological factors. Current treatments do not have satisfactory outcomes. Several basic studies have revealed the protective effect of trimetazidine on the heart, not only by metabolism modulation but also by relieving myocardial apoptosis, fibrosis, autophagy, and inflammation. Clinical studies have consistently indicated that trimetazidine acts as an adjunct to conventional treatments and improves the symptoms of heart failure. This review summarizes the basic pathological changes in the myocardium, with an emphasis on the alteration of cardiac metabolism in the development of heart failure. The clinical application of trimetazidine in heart failure and the mechanism of its protective effects on the myocardium are carefully discussed, as well as its main adverse effects. The intention of this review is to highlight this treatment as an effective alternative against heart failure and provide additional perspectives for future studies.

Established and Emerging Pharmacological Therapies for Post-Myocardial Infarction Patients with Heart Failure: a Review of the Evidence

After an episode of myocardial infarction (MI), patients remain at risk for recurrent ischemic events, heart failure (HF), and sudden death. Post-MI patients with left ventricular systolic dysfunction (LVSD) have an even greater risk of mortality and morbidity. Randomized clinical trials that included post-MI patients with LVSD have demonstrated that pharmacologic therapies aimed at preventing post-MI remodeling with neurohormonal antagonists can significantly improve short- and long-term outcomes, including death, reinfarction, and worsening HF. Recent trials have also demonstrated benefits in terms of cardiovascular event reduction with effective antithrombotic therapies and cholesterol-lowering agents in post-MI setting, especially in patients at very high risk such as those with LVSD. This paper reviews clinical trials that included post-MI patients with LVSD, with or without signs and symptoms of HF, assessing the efficacy of established and emerging pharmacological therapies.

Physiological monitoring in the complex multi-morbid heart failure patient - Introduction

Repeated physiological monitoring of comorbidities in heart failure (HF) is pivotal. This document introduces the main challenges related to physiological monitoring in the complex multimorbid HF patient, arising during an ESC consensus meeting on this topic.