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Omran E, Alzahrani AR, Ezzat SF, Ellithy G, Tarek M, Khairy E, Ghit MM, Elgeushy A, Ibrahim Al-Hazani TM, Aziz Ibrahim IA, Falemban AH, Bamagous GA, Elhawary NA, Jaremko M, Saied EM, Mohamed DI. Deciphering the therapeutic potential of trimetazidine in rheumatoid arthritis via targeting mi-RNA128a, TLR4 signaling pathway, and adenosine-induced FADD-microvesicular shedding: In vivo and in silico study. Front Pharmacol 2024; 15:1406939. [PMID: 38919260 PMCID: PMC11196411 DOI: 10.3389/fphar.2024.1406939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/22/2024] [Indexed: 06/27/2024] Open
Abstract
Rheumatoid arthritis (RA) is a debilitating autoimmune condition characterized by chronic synovitis, joint damage, and inflammation, leading to impaired joint functionality. Existing RA treatments, although effective to some extent, are not without side effects, prompting a search for more potent therapies. Recent research has revealed the critical role of FAS-associated death domain protein (FADD) microvesicular shedding in RA pathogenesis, expanding its scope beyond apoptosis to include inflammatory and immune pathways. This study aimed to investigate the intricate relationship between mi-RNA 128a, autoimmune and inflammatory pathways, and adenosine levels in modulating FADD expression and microvesicular shedding in a Freund's complete adjuvant (FCA) induced RA rat model and further explore the antirheumatoid potency of trimetazidine (TMZ). The FCA treated model exhibited significantly elevated levels of serum fibrogenic, inflammatory, immunological and rheumatological diagnostic markers, confirming successful RA induction. Our results revealed that the FCA-induced RA model showed a significant reduction in the expression of FADD in paw tissue and increased microvesicular FADD shedding in synovial fluid, which was attributed to the significant increase in the expression of the epigenetic miRNA 128a gene in addition to the downregulation of adenosine levels. These findings were further supported by the significant activation of the TLR4/MYD88 pathway and its downstream inflammatory IkB/NFB markers. Interestingly, TMZ administration significantly improved, with a potency similar to methotrexate (MTX), the deterioration effect of FCA treatment, as evidenced by a significant attenuation of fibrogenic, inflammatory, immunological, and rheumatological markers. Our investigations indicated that TMZ uniquely acted by targeting epigenetic miRNA128a expression and elevating adenosine levels in paw tissue, leading to increased expression of FADD of paw tissue and mitigated FADD microvesicular shedding in synovial fluid. Furthermore, the group treated with TMZ showed significant downregulation of TLR4/MYD88 and their downstream TRAF6, IRAK and NF-kB. Together, our study unveils the significant potential of TMZ as an antirheumatoid candidate, offering anti-inflammatory effects through various mechanisms, including modulation of the FADD-epigenetic regulator mi-RNA 128a, adenosine levels, and the TLR4 signaling pathway in joint tissue, but also attenuation of FADD microvesicular shedding in synovial fluid. These findings further highlight the synergistic administration of TMZ and MTX as a potential approach to reduce adverse effects of MTX while improving therapeutic efficacy.
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Affiliation(s)
- Enas Omran
- Department of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Abdullah R. Alzahrani
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Samar F. Ezzat
- Department of Histology and Cell Biology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ghada Ellithy
- Department of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Marwa Tarek
- Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Eman Khairy
- Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Department of Clinical Biochemistry, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Mohamed M. Ghit
- Department of Rheumatology and Rehabilitation, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Elgeushy
- Orthopedic Department, Faculty of Medicine, Alazhar University Hospitals, Cairo, Egypt
| | | | - Ibrahim Abdel Aziz Ibrahim
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Alaa Hisham Falemban
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Ghazi A. Bamagous
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Nasser A. Elhawary
- Department of Medical Genetics, College of Medicine, Umm Al-Qura University, Mecca, Saudi Arabia
| | - Mariusz Jaremko
- Smart-Health Initiative and Red Sea Research Center, Division of Biological and Environmental Sciences and Engineering, King Abdullah University of Science and Technology, Thuwal, Saudi Arabia
| | - Essa M. Saied
- Chemistry Department, Faculty of Science, Suez Canal University, Ismailia, Egypt
- Institute for Chemistry, Humboldt Universität zu Berlin, Berlin, Germany
| | - Doaa I. Mohamed
- Department of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Nalakath J, Pt R, Kadry A, Palathinkal AB, Praseen OK, Nelliyott I, Hebel C, Selvapalam N, Nagarajan ER. Comprehensive metabolite profiling of trimetazidine in camels using high-resolution accurate mass spectrometry: Implications for doping control. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2023; 37:e9626. [PMID: 37799033 DOI: 10.1002/rcm.9626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 10/07/2023]
Abstract
RATIONALE Trimetazidine and its metabolites are prohibited substances in sports. With a growing number of adverse findings in human athletes, it is crucial to develop doping control strategies that include screening for trimetazidine in animal sports. This study aims to detect and characterize trimetazidine and its metabolites for doping control in camel racing. METHODS Camel urine and plasma samples were collected from four healthy animals following a single oral dose of trimetazidine. In vitro investigations were conducted using camel liver samples. Liquid-liquid extraction and solid-phase extraction techniques were employed for the extraction of trimetazidine metabolites from plasma and urine matrices. The metabolites were analyzed using a Thermo Orbitrap Exploris LC-MS system with optimized settings to achieve maximum sensitivity and accurate mass measurements. RESULTS Comprehensive metabolite profiling of trimetazidine in camels revealed the identification of seven phase I and five phase II metabolites. Phase I metabolites were primarily formed through dealkylation, while phase II metabolites were dominated by glucuronide conjugation of demethylated trimetazidine. The findings provided insights into the distinct metabolic pathways and biotransformation patterns of trimetazidine in camels under the experimental conditions. CONCLUSION The developed method enables detection and characterization of trimetazidine and its metabolites in camels. The identified metabolites have the potential to serve as marker metabolites for trimetazidine abuse in camel racing. This study provides valuable insights into the metabolism of trimetazidine in camels.
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Affiliation(s)
- Jahfar Nalakath
- Camel Forensic Laboratory - Central Veterinary Research Laboratory, Dubai, UAE
- Department of Chemistry, Kalasalingam Academy of Research and Education, Krishnan Kovil, Tamil Nadu, India
| | - Rasik Pt
- Camel Forensic Laboratory - Central Veterinary Research Laboratory, Dubai, UAE
| | - Ahmed Kadry
- Camel Forensic Laboratory - Central Veterinary Research Laboratory, Dubai, UAE
| | | | | | | | - Christiana Hebel
- Camel Forensic Laboratory - Central Veterinary Research Laboratory, Dubai, UAE
| | - N Selvapalam
- Department of Chemistry, Kalasalingam Academy of Research and Education, Krishnan Kovil, Tamil Nadu, India
| | - E R Nagarajan
- Department of Chemistry, Kalasalingam Academy of Research and Education, Krishnan Kovil, Tamil Nadu, India
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Bubnova MG, Aronov DM. Efficacy of trimetazidine - an inhibitor of free fatty acids oxidation in the treatment of patients with stable angina pectoris and heart failure. KARDIOLOGIIA 2021; 61:65-76. [PMID: 34882080 DOI: 10.18087/cardio.2021.11.n1801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/09/2021] [Indexed: 06/13/2023]
Abstract
Aim To evaluate efficacy of modified-release trimetazidine (TMZ) included into the standard therapy for patients with stable angina and chronic heart failure (CHF) as a part of a subgroup analysis in the PERSPECTIVE study.Material and methods The study included 806 patients: group 1 (n=691), patients receiving a standard therapy and modified-release TMZ (TMZ group); and group 2 (n=115), patients receiving a standard therapy (control group). Total duration of the study was 12 months.Results In the TMZ group, the weekly number of angina attacks decreased by 41.9% (p<0.0001) in 2 months and by 69.6 % (from baseline, р<0.0001) in 12 months, and the frequency of nitroglycerine dosing decreased by 40.8 % (р<0.0001) and 67.7 % (р<0.0001), respectively. In the control group, the respective values did not change. In the TMZ group compared to the control group, the QT interval was shorter (7.9 %; р<0.05), the left ventricular (LV) end-systolic dimension was reduced (13.4 %; р<0.01), interventricular septal thickness and LV posterior wall thickness were decreased (9.5 %; р<0.01 and 12.2 %; р<0.01, respectively), and the ejection fraction was increased (11.4; р<0.05). Following the TMZ treatment, the leukocyte count in peripheral blood was decreased (5.3 %; р<0.01) and the serum concentration of high-sensitivity C-reactive protein was decreased (30.7 %; р<0.01) vs. increases of these indexes in the control group (17.9 %; р<0.05 and 17.8 %; р<0.05, respectively). The proportion of patients hospitalized for exacerbation of CHF or angina for 12 months was 8.6 % in the TMZ group and 15.7 % in the control group (p=0,001).Conclusion In patients with stable angina and CHF, inclusion of modified-release TMZ into the standard therapy decreases the number of angina attacks, reduces the activity of inflammatory factors, and improves the course of disease.
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Affiliation(s)
- M G Bubnova
- National Medical Research Center for Therapy and Preventive Medicine, Moscow
| | - D M Aronov
- National Medical Research Center for Therapy and Preventive Medicine, Moscow
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Novel Therapeutic Targets for the Treatment of Right Ventricular Remodeling: Insights from the Pulmonary Artery Banding Model. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168297. [PMID: 34444046 PMCID: PMC8391744 DOI: 10.3390/ijerph18168297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 07/31/2021] [Accepted: 08/02/2021] [Indexed: 12/15/2022]
Abstract
Right ventricular (RV) function is the main determinant of the outcome of patients with pulmonary hypertension (PH). RV dysfunction develops gradually and worsens progressively over the course of PH, resulting in RV failure and premature death. Currently, approved therapies for the treatment of left ventricular failure are not established for the RV. Furthermore, the direct effects of specific vasoactive drugs for treatment of pulmonary arterial hypertension (PAH, Group 1 of PH) on RV are not fully investigated. Pulmonary artery banding (PAB) allows to study the pathogenesis of RV failure solely, thereby testing potential therapies independently of pulmonary vascular changes. This review aims to discuss recent studies of the mechanisms of RV remodeling and RV-directed therapies based on the PAB model.
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Heshmatzadeh Behzadi A, Amoozgar B, Jain S, Velasco N, Zahid U, Abbasi H, Alasadi L, Prince MR. Trimetazidine reduces contrast-induced nephropathy in patients with renal insufficiency undergoing coronary angiography and angioplasty: A systematic review and meta-analysis (PRISMA). Medicine (Baltimore) 2021; 100:e24603. [PMID: 33725824 PMCID: PMC7969219 DOI: 10.1097/md.0000000000024603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/26/2020] [Accepted: 01/12/2021] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES This systematic review and meta-analysis assesses the utility of trimetazidine (TMZ) to prevent contrast induced nephropathy (CIN) in patients with renal insufficiency undergoing coronary angiography and angioplasty. MATERIALS AND METHODS This meta-analysis was formulated and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of databases was conducted by 2 researchers independently for clinical trials, comparing hydration plus TMZ vs conventional hydration alone for prevention of CIN through January 2020. All patients had renal insufficiency (defined as GFR < 89 ml/minute/1.73 m2) and the outcome of interest was the incidence of contrast induced acute kidney injury. The odds ratio (OR) was estimated with 95% confidence interval (CI). Heterogeneity was reported with the I2 statistic, using a fixed-effects model, and >50% of I2 was considered to be statistically significant. RESULTS Eleven studies, 1611 patients, met the inclusion/exclusion criteria: 797 patients comprised the TMZ plus hydration group and the remaining 814 patients comprised the control (hydration only) group. Heterogeneity was low I2 = 0%, P = .84, and the heterogeneity of each study was also low. The incidence of CIN in the TMZ plus hydration group was 6.6% (53/797), while the incidence of CIN in the control (hydration only) group was 20% (165/814). Pooled analysis of all studies showed TMZ reduced incidence of CIN compared to saline hydration alone (OR risk 0.30, 95% CI 0.21, 0.42, P < .0001). CONCLUSION TMZ added to hydration reduces CIN in renal insufficiency patients undergoing coronary angiography.
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Affiliation(s)
| | - Behzad Amoozgar
- Department of Medicine, Jersey Shore University Medical Center, Perth Amboy Divisions, New Jersey
| | - Shalini Jain
- CHI Health Creighton University Medical Center, Omaha
| | - Noel Velasco
- Department of Radiology, Yale New Haven, Bridgeport Hospital, Connecticut
| | - Umar Zahid
- Brookdale University Hospital Medical Center, New York
| | - Hamidreza Abbasi
- Hackensack Meridian Health and JFK Neuroscience Institute, Edison, NJ
| | - Lutfi Alasadi
- Brookdale University Hospital Medical Center, New York
| | - Martin R. Prince
- Department of Radiology, Weill Cornell Medicine
- Department of Radiology, Columbia College of Physicians and Surgeons, New York
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Abstract
The article discusses pharmacologic and interventional therapeutic options for patients with refractory angina. Refractory angina refers to long-lasting symptoms (≥3 months) due to established reversible ischemia in the presence of obstructive coronary artery disease, which cannot be controlled by escalating medical therapy with second-line and third-line pharmacologic agents, bypass grafting, or stenting. Due to an aging population, increased number of comorbidities, and advances in coronary artery disease treatment, incidence of refractory angina is growing. Although the number of therapeutic options is increasing, there is a lack of randomized clinical trials that could help create recommendations for this group of patients.
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Affiliation(s)
- Marcin Makowski
- Department of Interventional Cardiology, Medical University of Lodz, Central Clinical Hospital, ul. Pomorska 251, Lodz 92-213, Poland.
| | | | - Marzenna Zielińska
- Department of Interventional Cardiology, Medical University of Lodz, Central Clinical Hospital, ul. Pomorska 251, Lodz 92-213, Poland
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Dasgupta A, Wu D, Tian L, Xiong PY, Dunham-Snary KJ, Chen KH, Alizadeh E, Motamed M, Potus F, Hindmarch CCT, Archer SL. Mitochondria in the Pulmonary Vasculature in Health and Disease: Oxygen-Sensing, Metabolism, and Dynamics. Compr Physiol 2020; 10:713-765. [PMID: 32163206 DOI: 10.1002/cphy.c190027] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In lung vascular cells, mitochondria serve a canonical metabolic role, governing energy homeostasis. In addition, mitochondria exist in dynamic networks, which serve noncanonical functions, including regulation of redox signaling, cell cycle, apoptosis, and mitochondrial quality control. Mitochondria in pulmonary artery smooth muscle cells (PASMC) are oxygen sensors and initiate hypoxic pulmonary vasoconstriction. Acquired dysfunction of mitochondrial metabolism and dynamics contribute to a cancer-like phenotype in pulmonary arterial hypertension (PAH). Acquired mitochondrial abnormalities, such as increased pyruvate dehydrogenase kinase (PDK) and pyruvate kinase muscle isoform 2 (PKM2) expression, which increase uncoupled glycolysis (the Warburg phenomenon), are implicated in PAH. Warburg metabolism sustains energy homeostasis by the inhibition of oxidative metabolism that reduces mitochondrial apoptosis, allowing unchecked cell accumulation. Warburg metabolism is initiated by the induction of a pseudohypoxic state, in which DNA methyltransferase (DNMT)-mediated changes in redox signaling cause normoxic activation of HIF-1α and increase PDK expression. Furthermore, mitochondrial division is coordinated with nuclear division through a process called mitotic fission. Increased mitotic fission in PAH, driven by increased fission and reduced fusion favors rapid cell cycle progression and apoptosis resistance. Downregulation of the mitochondrial calcium uniporter complex (MCUC) occurs in PAH and is one potential unifying mechanism linking Warburg metabolism and mitochondrial fission. Mitochondrial metabolic and dynamic disorders combine to promote the hyperproliferative, apoptosis-resistant, phenotype in PAH PASMC, endothelial cells, and fibroblasts. Understanding the molecular mechanism regulating mitochondrial metabolism and dynamics has permitted identification of new biomarkers, nuclear and CT imaging modalities, and new therapeutic targets for PAH. © 2020 American Physiological Society. Compr Physiol 10:713-765, 2020.
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Affiliation(s)
- Asish Dasgupta
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Danchen Wu
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Lian Tian
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ping Yu Xiong
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Kuang-Hueih Chen
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Elahe Alizadeh
- Department of Medicine, Queen's Cardiopulmonary Unit (QCPU), Translational Institute of Medicine (TIME), Queen's University, Kingston, Ontario, Canada
| | - Mehras Motamed
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - François Potus
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Charles C T Hindmarch
- Department of Medicine, Queen's Cardiopulmonary Unit (QCPU), Translational Institute of Medicine (TIME), Queen's University, Kingston, Ontario, Canada
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.,Kingston Health Sciences Centre, Kingston, Ontario, Canada.,Providence Care Hospital, Kingston, Ontario, Canada
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Seecheran N, Seebalack V, Seecheran R, Maharaj A, Boodhai B, Seecheran V, Persad S, Motilal S, Tello-Montoliu A, Schneider D. TRimetazidine as an Agent to affeCt clopidogrEl Response: The TRACER Study. Cardiol Ther 2019; 8:229-237. [PMID: 31292901 PMCID: PMC6828882 DOI: 10.1007/s40119-019-0139-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION This prospective study aimed to determine whether trimetazidine (TMZ) alters the pharmacodynamic (PD) effects of clopidogrel. METHODS Patients with stable coronary artery disease (SCAD) (n = 24) who were actively treated with dual antiplatelet therapy (DAPT) of aspirin 81 mg daily and clopidogrel 75 mg daily were recruited. Platelet function was measured with the VerifyNow P2Y12 assay (Accriva Diagnostics, San Diego, CA, USA) and assessed before the initiation of and after 14 days of treatment with TMZ. Results were compared using a paired t test. RESULTS Almost 80% of the study population were of South Asian descent and had diabetes mellitus (DM). P2Y12 reaction units (PRUs) were higher in patients on TMZ (204 ± 56 compared with 174 ± 71 before TMZ, p = 0.005). The average increase in PRU score was 29 (95% confidence interval 8.8-49.7). Before TMZ, the proportion of patients with high on-treatment platelet reactivity (PRU > 208 units) was 25%, which increased to 42% for patients on TMZ. CONCLUSION Higher platelet reactivity was seen in patients on TMZ, suggesting that TMZ attenuated the PD effects of clopidogrel in this study of a predominantly South Asian diabetic subpopulation. Alternative therapies should be considered and further research is warranted. TRIAL REGISTRATION ClinicalTrials.gov number, NCT03603249.
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Affiliation(s)
- Naveen Seecheran
- Department of Clinical Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago.
| | - Victoria Seebalack
- Department of Clinical Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Rajeev Seecheran
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Aarti Maharaj
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Brent Boodhai
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Valmiki Seecheran
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Sangeeta Persad
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Shastri Motilal
- Department of Clinical Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | | | - David Schneider
- Cardiovascular Research Institute of Vermont, Colchester, VT, USA
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Coats CJ, Pavlou M, Watkinson OT, Protonotarios A, Moss L, Hyland R, Rantell K, Pantazis AA, Tome M, McKenna WJ, Frenneaux MP, Omar R, Elliott PM. Effect of Trimetazidine Dihydrochloride Therapy on Exercise Capacity in Patients With Nonobstructive Hypertrophic Cardiomyopathy: A Randomized Clinical Trial. JAMA Cardiol 2019; 4:230-235. [PMID: 30725091 PMCID: PMC6439550 DOI: 10.1001/jamacardio.2018.4847] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 12/04/2018] [Indexed: 12/18/2022]
Abstract
Importance Hypertrophic cardiomyopathy causes limiting symptoms in patients, mediated partly through inefficient myocardial energy use. There is conflicting evidence for therapy with inhibitors of myocardial fatty acid metabolism in patients with nonobstructive hypertrophic cardiomyopathy. Objective To determine the effect of oral therapy with trimetazidine, a direct inhibitor of fatty acid β-oxidation, on exercise capacity in patients with symptomatic nonobstructive hypertrophic cardiomyopathy. Design, Setting, and Participants This randomized, placebo-controlled, double-blind clinical trial at The Heart Hospital, University College London Hospitals, London, United Kingdom was performed between May 31, 2012, and September 8, 2014. The trial included 51 drug-refractory symptomatic (New York Heart Association class ≥2) patients aged 24 to 74 years with a maximum left ventricular outflow tract gradient 50 mm Hg or lower and a peak oxygen consumption during exercise of 80% or less predicted value for age and sex. Statistical analysis was performed from March 1, 2016 through July 4, 2018. Interventions Participants were randomly assigned to trimetazidine, 20 mg, 3 times daily (n = 27) or placebo (n = 24) for 3 months. Main Outcomes and Measures The primary end point was peak oxygen consumption during upright bicycle ergometry. Secondary end points were 6-minute walk distance, quality of life (Minnesota Living with Heart Failure questionnaire), frequency of ventricular ectopic beats, diastolic function, serum N-terminal pro-brain natriuretic peptide level, and troponin T level. Results Of 49 participants who received trimetazidine (n = 26) or placebo (n = 23) and completed the study, 34 (70%) were male; the mean (SD) age was 50 (13) years. Trimetazidine therapy did not improve exercise capacity, with patients in the trimetazidine group walking 38.4 m (95% CI, 5.13 to 71.70 m) less than patients in the placebo group at 3 months after adjustment for their baseline walking distance measurements. After adjustment for baseline values, peak oxygen consumption was 1.35 mL/kg per minute lower (95% CI, -2.58 to -0.11 mL/kg per minute; P = .03) in the intervention group after 3 months. Conclusions and Relevance In symptomatic patients with nonobstructive hypertrophic cardiomyopathy, trimetazidine therapy does not improve exercise capacity. Pharmacologic therapy for this disease remains limited. Trial Registration ClinicalTrials.gov identifier: NCT01696370.
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Affiliation(s)
- Caroline J. Coats
- University College London Institute of Cardiovascular Science, London, United Kingdom
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Menelaos Pavlou
- Department of Statistical Science, University College London, London, United Kingdom
| | - Oliver T. Watkinson
- University College London Institute of Cardiovascular Science, London, United Kingdom
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health National Health Service Trust, West Smithfield, London, United Kingdom
| | - Alexandros Protonotarios
- University College London Institute of Cardiovascular Science, London, United Kingdom
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health National Health Service Trust, West Smithfield, London, United Kingdom
| | - Linda Moss
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health National Health Service Trust, West Smithfield, London, United Kingdom
| | | | - Khadija Rantell
- University College London Institute of Neurology, London, United Kingdom
| | | | - Maite Tome
- St George’s Hospital, London, United Kingdom
| | - William J. McKenna
- University College London Institute of Cardiovascular Science, London, United Kingdom
| | | | - Rumana Omar
- Department of Statistical Science, University College London, London, United Kingdom
| | - Perry M. Elliott
- University College London Institute of Cardiovascular Science, London, United Kingdom
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health National Health Service Trust, West Smithfield, London, United Kingdom
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Anti-Anginal Effectiveness and Tolerability of Trimetazidine Modified Release 80 Mg Once Daily in Stable Angina Patients in Real-World Practice. Adv Ther 2018; 35:1368-1377. [PMID: 30105656 PMCID: PMC6133142 DOI: 10.1007/s12325-018-0756-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Indexed: 12/19/2022]
Abstract
Introduction Trimetazidine (TMZ) was shown to reduce angina symptoms and increase the exercise capacity in stable angina (SA) patients. A new formulation allowing a once-daily (od) dosage could improve patients’ satisfaction and adherence. Methods ODA was a 3-month, observational, multicenter, prospective Russian study
in SA patients with persistent symptoms despite therapy. Angina attack frequency, short-acting nitrate (SAN) consumption, adherence to antianginal medications, and overall efficacy and tolerability of TMZ 80 mg od were assessed in a real-world setting. Results A total of 3066 patients were included (mean age 62.8, 48% male). After 3 months, TMZ 80 mg od treatment led to a significant (p < 0.001) decrease in angina attack frequency (from 4.7 ± 3.5 to 0.9 ± 1.3/week) and SAN use (from 4.5 ± 3.9 to 0.7 ± 1.3/week). Overall tolerability and effectiveness were rated as “very good” by the majority of physicians. Medication adherence improved significantly, with good adherence reported by 56% of patients (vs. 24% at baseline, p < 0.0001) and non-adherence by 3% (vs. 36% at baseline, p < 0.0001) at month 3. Patient satisfaction with TMZ od was 9.5 [on a scale of 1 to 10 (very satisfied)]. Patients reported improved physical activity: more patients reported no limitations (15% vs. 1% at baseline p < 0.01), slight limitation (46% vs. 5% at baseline, p < 0.001) or moderate limitation (30% vs. 23%, p < 0.01) and fewer patients reported substantial limitation (8% vs. 52% at baseline, p < 0.001) or very marked reduction (1% vs. 19% at baseline, p < 0.01) at month 3. Conclusion In this prospective, observational study, TMZ 80 mg od effectively reduced angina attacks and SAN consumption, improved physical activity and adherence and was well tolerated in chronic SA patients. Trial Registration ISRCTN registry Identifier, ISRCTN97780949. Funding Servier. Plain Language Summary Plain language summary available for this article.
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Park KE, Conti CR. Non-PCI/CABG therapies for refractory angina. Trends Cardiovasc Med 2018; 28:223-228. [DOI: 10.1016/j.tcm.2017.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 12/19/2022]
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Al Batran R, Almutairi M, Ussher JR. Glucagon-like peptide-1 receptor mediated control of cardiac energy metabolism. Peptides 2018; 100:94-100. [PMID: 29412838 DOI: 10.1016/j.peptides.2017.12.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/04/2017] [Accepted: 12/06/2017] [Indexed: 12/16/2022]
Abstract
Glucagon-like peptide-1 receptor (GLP-1R) agonists are frequently used to improve glycemia in patients with type 2 diabetes (T2D). Recent data from cardiovascular outcomes trials for the GLP-1R agonists, liraglutide and semaglutide, have also demonstrated significant reductions in death rates from cardiovascular causes in patients with T2D. As cardiovascular death is the number one cause of death in patients with T2D, understanding the mechanisms by which GLP-1R agonists such as liraglutide and semaglutide improve cardiac function is essential. Yet despite strong evidence from preclinical and clinical studies supporting the cardioprotective actions of GLP-1R agonists, the precise mechanism(s) by which this drug-class for T2D may produce these beneficial actions remains enigmatic. Negligible GLP-1R expression in ventricular cardiac myocytes suggests that GLP-1R agonist-induced cardioprotection is likely partially attributed to indirect actions on peripheral tissues other than the heart. Because insulin increases glucose oxidation, whereas glucagon increases fatty acid oxidation in the heart, GLP-1R agonist-induced increases and decreases in insulin and glucagon secretion, respectively, may modify cardiac energy metabolism in T2D patients. This may represent a potential mechanism for GLP-1R agonist-induced cardioprotection in T2D, as increases in fatty acid oxidation and decreases in glucose oxidation are frequently observed in the hearts of animals and human subjects with T2D.
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Affiliation(s)
- Rami Al Batran
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB Canada; Alberta Diabetes Institute, University of Alberta, Edmonton, AB Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB Canada
| | - Malak Almutairi
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB Canada; Alberta Diabetes Institute, University of Alberta, Edmonton, AB Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB Canada
| | - John R Ussher
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB Canada; Alberta Diabetes Institute, University of Alberta, Edmonton, AB Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB Canada.
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13
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Abunahlah N, Elawaisi A, Velibeyoglu FM, Sancar M. Drug related problems identified by clinical pharmacist at the Internal Medicine Ward in Turkey. Int J Clin Pharm 2018; 40:360-367. [PMID: 29380236 DOI: 10.1007/s11096-017-0585-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 12/20/2017] [Indexed: 11/28/2022]
Abstract
Background Drug-related problems (DRPs) interfere with patient optimal therapeutic outcomes and may be associated with higher morbidity, mortality and healthcare expenditures. Objective This study aimed to identify DRPs and their causes in a Turkish hospital. Setting Bakirkoy Dr. Sadi Konuk Teaching and Research Hospital, Internal Medicine Ward, Istanbul, Turkey. Method Cross-sectional study included a total of 100 patients. Patient demographics, medications, and history were evaluated. Data regarding recent medications were analyzed by two clinical pharmacists and an Internal Medicine physician. The DRPs were identified via V7.0 PCNE classification. Lexicomp® was used to assess the drug-drug interactions. UpToDate® recommendations and national guidelines were applied in the assessment of compliance with approved medication procedures. Main outcome measures Number and causes of the potential DRPs. Results At least one potential DRP was seen in 80% of the patients and 163 potential DRPs were identified (average = 1.6 DRPs/patient). The most common causes of DRPs were errors in drug selection (44.78%), dose selection (27.61%) and medication procedures (21.47%). There were significant correlations (p < 0.05) between DRPs and age (r = 0.4), number of drugs used (r = 0.32), duration of hospitalization (r = 0.25), renal impairment (r = - 0.34) and inflammation (r = 0.31). Conclusion The majority of the patients had DRPs. Patients with renal impairment, inflammation, polypharmacy or an extended hospital stay had a much higher chance of developing DRPs.
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Affiliation(s)
- Nibal Abunahlah
- Clinical Pharmacy Department, School of Pharmacy, Altinbas University, Istanbul, Turkey.
| | - Anfal Elawaisi
- Clinical Pharmacy Department, School of Pharmacy, Altinbas University, Istanbul, Turkey
| | - Fatih Mehmet Velibeyoglu
- Internal Medicine Department, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - Mesut Sancar
- Clinical Pharmacy Department, School of Pharmacy, Marmara University, Istanbul, Turkey
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14
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Abstract
INTRODUCTION Angina pectoris is the most prevalent symptomatic manifestation of ischemic heart disease, frequently leads to a poor quality of life, and is a major cause of medical resource consumption. Since the early descriptions of nitrite and nitrate in the 19th century, there has been considerable advancement in the pharmacologic management of angina. Areas covered: Management of chronic angina is often challenging for clinicians. Despite introduction of several pharmacological agents in last few decades, a significant proportion of patients continue to experience symptoms (i.e., refractory angina) with subsequent disability. For the purpose of this review, we searched PubMed and Cochrane databases from inception to August 2016 for the most clinically relevant publications that guide current practice in angina therapy and its development. In this article, we briefly review the pathophysiology of angina and mechanism-based classification of current therapy. This is followed by evidence-based insight into the traditional and novel pharmacotherapeutic agents, highlighting their clinical usefulness. Expert opinion: Considering the wide array of available therapies with different mechanism efficacy and limiting factors, a personalized approach is essential, particularly for patients with refractory angina. Ongoing research with novel pharmacologic modalities is likely to provide new options for management of angina.
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Affiliation(s)
- Ankur Jain
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Islam Y Elgendy
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Mohammad Al-Ani
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Nayan Agarwal
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Carl J Pepine
- a Department of Medicine , University of Florida , Gainesville , FL , USA
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15
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Abstract
All of the following traditional agents for the management of stable angina pectoris include the symptomatic treatment with heart rate–lowering agents such as β-blockers or non-dihydropyridine Ca-channel blockers, or ivabradine—the first selective sinus node If channel inhibitor—vasodilatators and preventive use of angiotensin-converting enzyme inhibitors affect the parameters of circulation directly. Trimetazidine exerts its anti-ischemic action by modulating cardiac metabolism without altering the hemodynamic functions, therefore represents an excellent complementary potential to the conventional angina treatment. It has a beneficial effect on the inflammatory profile and endothelial function and shows diverse benefits by reducing the number and the intensity of angina attacks and improving the clinical signs and symptoms of myocardial ischemia given as monotherapy as well as combined with other antianginal agents. Patients undergoing coronary revascularization procedures or with comorbid left ventricular dysfunction and diabetes mellitus also benefit from the protective effects of trimetazidine.
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16
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Kanorskii SG, Smolenskaya NV. [Triple antianginal combinations in the treatment of elderly and senile patients with stable angina]. TERAPEVT ARKH 2017; 88:33-40. [PMID: 28139557 DOI: 10.17116/terarkh2016881233-40] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- S G Kanorskii
- Kuban State Medical University, Ministry of Health of Russia, Krasnodar, Russia
| | - N V Smolenskaya
- Kuban State Medical University, Ministry of Health of Russia, Krasnodar, Russia
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17
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Elgendy IY, Winchester DE, Pepine CJ. Experimental and early investigational drugs for angina pectoris. Expert Opin Investig Drugs 2016; 25:1413-1421. [PMID: 27791405 DOI: 10.1080/13543784.2016.1254617] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Ischemic heart disease (IHD) is a major cause of death and disability among Western countries and angina pectoris is the most prevalent symptomatic manifestation. Strategies to improve management of chronic stable angina are a priority. Areas covered: A comprehensive review was conducted using the Medline and Cochrane databases as well as the clinical trial databases in the United States and Europe. Traditional therapies for angina will be discussed. This review particularly emphasizes investigational therapies for angina (including pharmacological agents, cell and gene based therapies, and herbal medications). Expert opinion: There has been renewed interest in older anti-angina agents (e.g., perhexiline, amiodarone, and phosphodiestrase-5 inhibitors). Other anti-inflammatory agents (e.g., allopurinol and febuxostat) are currently undergoing evaluation for angina therapy. Therapeutic angiogenesis continues to face some challenges. Future trials should evaluate the optimum patient population that would benefit from this form of therapy.
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Affiliation(s)
- Islam Y Elgendy
- a Division of Cardiovascular Medicine , University of Florida, and North Florida/South Georgia Veterans Health System , Gainesville , FL , USA
| | - David E Winchester
- a Division of Cardiovascular Medicine , University of Florida, and North Florida/South Georgia Veterans Health System , Gainesville , FL , USA
| | - Carl J Pepine
- a Division of Cardiovascular Medicine , University of Florida, and North Florida/South Georgia Veterans Health System , Gainesville , FL , USA
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18
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Manolis AJ, Poulimenos LE, Ambrosio G, Kallistratos MS, Lopez-Sendon J, Dechend R, Mancia G, Camm AJ. Medical treatment of stable angina: A tailored therapeutic approach. Int J Cardiol 2016; 220:445-53. [DOI: 10.1016/j.ijcard.2016.06.150] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/18/2016] [Accepted: 06/24/2016] [Indexed: 01/17/2023]
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19
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Kourlaba G, Gourzoulidis G, Andrikopoulos G, Tsioufis K, Beletsi A, Maniadakis N. Economic evaluation of trimetazidine in the management of chronic stable angina in Greece. BMC Health Serv Res 2016; 16:520. [PMID: 27678370 PMCID: PMC5039874 DOI: 10.1186/s12913-016-1779-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 09/22/2016] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Georgia Kourlaba
- The Stavros Niarchos Foundation-Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), National and Kapodistrian University of Athens, School of Medicine, Thivon & Papadiamantopoulou, Athens, 115 27, Greece.
| | - George Gourzoulidis
- Department of Health Services Organization & Management, National School of Public Health, Athens, Greece
| | | | - Konstantinos Tsioufis
- Hippokration General Hospital, First Cardiology Clinic, University of Athens, Athens, Greece
| | | | - Nikos Maniadakis
- Department of Health Services Organization & Management, National School of Public Health, Athens, Greece
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20
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Giannopoulos AA, Giannoglou GD, Chatzizisis YS. Pharmacological approaches of refractory angina. Pharmacol Ther 2016; 163:118-31. [DOI: 10.1016/j.pharmthera.2016.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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21
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Taegtmeyer H, Young ME, Lopaschuk GD, Abel ED, Brunengraber H, Darley-Usmar V, Des Rosiers C, Gerszten R, Glatz JF, Griffin JL, Gropler RJ, Holzhuetter HG, Kizer JR, Lewandowski ED, Malloy CR, Neubauer S, Peterson LR, Portman MA, Recchia FA, Van Eyk JE, Wang TJ. Assessing Cardiac Metabolism: A Scientific Statement From the American Heart Association. Circ Res 2016; 118:1659-701. [PMID: 27012580 DOI: 10.1161/res.0000000000000097] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In a complex system of interrelated reactions, the heart converts chemical energy to mechanical energy. Energy transfer is achieved through coordinated activation of enzymes, ion channels, and contractile elements, as well as structural and membrane proteins. The heart's needs for energy are difficult to overestimate. At a time when the cardiovascular research community is discovering a plethora of new molecular methods to assess cardiac metabolism, the methods remain scattered in the literature. The present statement on "Assessing Cardiac Metabolism" seeks to provide a collective and curated resource on methods and models used to investigate established and emerging aspects of cardiac metabolism. Some of those methods are refinements of classic biochemical tools, whereas most others are recent additions from the powerful tools of molecular biology. The aim of this statement is to be useful to many and to do justice to a dynamic field of great complexity.
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22
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Ambrosio G, Tamargo J, Grant PJ. Non-haemodynamic anti-anginal agents in the management of patients with stable coronary artery disease and diabetes: A review of the evidence. Diab Vasc Dis Res 2016; 13:98-112. [PMID: 26873904 DOI: 10.1177/1479164115609028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Patients with coronary artery disease and concomitant diabetes mellitus tend to have more extensive vessel disease than non-diabetes mellitus coronary artery disease patients, are at high risk of adverse cardiovascular events and suffer from a great anginal burden. Very few trials have specifically addressed the issue of optimal anti-anginal therapy in coronary artery disease patients who also have diabetes mellitus. Among 'classical' anti-anginal agents, recent guidelines do not specifically recommend any molecule over others; however, European Society of Cardiology guidelines acknowledge that favourable data in patients with concomitant diabetes mellitus and coronary artery disease are available for trimetazidine and ranolazine, two anti-anginal agents with a non-haemodynamic mechanism of action. The aim of this article is to review available evidence supporting the anti-anginal efficacy of these two drugs in the difficult-to-treat population of diabetes mellitus patients, including their effects on glycated haemoglobin (HbA1c), a measure of medium-term glycaemic control. Although direct head-to-head comparisons have not been performed, available evidence favours ranolazine as an effective anti-anginal agent over trimetazidine in this population. In addition, ranolazine lowers HbA1c, indicating that it may improve glycaemic control in patients with diabetes mellitus. Conversely, scanty data are available on the metabolic effects of trimetazidine in this cohort of patients. Thus, ranolazine may represent a valuable therapeutic option in stable coronary artery disease patients with diabetes mellitus.
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Affiliation(s)
- Giuseppe Ambrosio
- Division of Cardiology, School of Medicine, University of Perugia, Perugia, Italy
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Peter J Grant
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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23
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Milinković I, Rosano G, Lopatin Y, Seferović PM. The Role of Ivabradine and Trimetazidine in the New ESC HF Guidelines. Card Fail Rev 2016; 2:123-129. [PMID: 28785466 DOI: 10.15420/cfr.2016:13:1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The prevalence of heart failure (HF) is increasing, representing a major cause of death and disability, and a growing financial burden on healthcare systems. Despite the use of effective treatments with both drugs and devices, mortality remains high. There is therefore a need for new and effective therapeutic agents. Ivabradine is a specific sinus node inhibiting agent that was approved in 2005 by the European Medicines Agency, alone or in combination with a beta-blocker. Trimetazidine is a cytoprotective, anti-ischaemic agent established in the treatment of angina pectoris. In the 2012 European Society of Cardiology (ESC) guidelines for diagnosis and treatment of HF, ivabradine was recommended in symptomatic HF patients who are in sinus rhythm with left ventricular ejection fraction ≤35 % and heart rate higher than 70 beats per minute, despite optimal medical therapy, including maximally tolerated dose of beta-blocker. The role of trimetazidine in this setting was not mentioned. In the 2016 ESC guidelines, recommendations for ivabradine are unchanged but trimetazidine is included for the treatment of angina pectoris with HF. This article discusses the need for new therapeutic options in HF and reviews clinical evidence in support of these two therapeutic options.
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Affiliation(s)
- Ivan Milinković
- Department of Cardiology,Clinical Centre of Serbia, Belgrade, Serbia
| | - Giuseppe Rosano
- IRCCS San Raffaele,Rome, Italy.,Cardiovascular and Cell Sciences Institute,St George's University of London, London, UK
| | - Yuri Lopatin
- Volgograd Medical University,Cardiology Centre, Volgograd, Russia
| | - Petar M Seferović
- Department of Cardiology,Clinical Centre of Serbia, Belgrade, Serbia
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24
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Abstract
With improvements in survival from coronary artery disease (CAD) and an ageing population, refractory angina (RA) is becoming an increasingly common clinical problem facing clinicians in routine clinical practice. These patients experience chronic symptoms in the context of CAD, characterised by angina-type pain, which is uncontrolled despite optimal pharmacological, interventional and surgical therapy. Although mortality rates are no worse in this cohort, patients experience a significantly impaired quality of life with disproportionately high utilisation of healthcare services. It has been increasingly recognised that the needs of RA patients are multifactorial and best provided by specialist multi-disciplinary units. In this review, we consider the variety of therapies available to clinicians in the management of RA and discuss the promise of novel treatments.
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Affiliation(s)
- Kevin Cheng
- Specialist Angina Service, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Heart Science, National Heart and Lung Institute, Imperial College London, London, UK
| | - Paul Sainsbury
- Department of Cardiology, Bradford Royal Infirmary, Bradford, UK
| | - Michael Fisher
- Institute for Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital NHS Trust and Royal Liverpool and Broadgreen NHS Trust, Liverpool, UK
| | - Ranil de Silva
- Specialist Angina Service, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Vascular Science, National Heart and Lung Institute, Imperial College London, London, UK
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25
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Pradhan A. Metabolic management of heart disease. JOURNAL OF THE PRACTICE OF CARDIOVASCULAR SCIENCES 2016. [DOI: 10.4103/jpcs.jpcs_92_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Winchester DE, Pepine CJ. Angina treatments and prevention of cardiac events: an appraisal of the evidence. Eur Heart J Suppl 2015; 17:G10-G18. [PMID: 26740801 DOI: 10.1093/eurheartj/suv054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Angina pectoris is the symptomatic manifestation of transient myocardial ischaemia. At the most fundamental level, angina arises when myocardial oxygen demand exceeds the ability of the coronary circulation to provide adequate oxygen delivery to maintain normal myocardial metabolic function. In vivo, the balance of oxygen demand and delivery is a complex physiological process that can be altered by a variety of interventions. Lifestyle modification is a cornerstone of cardiovascular disease management, with or without angina. Additional pharmaceutical and physical interventions are usually applied to patients with angina. Mechanisms of action for these interventions include heart rate modulation, vascular smooth muscle relaxation, metabolic manipulation, revascularization, and others. A number of these interventions have overlapping mechanisms that target angina. Additionally, some interventions may directly or indirectly prevent or delay adverse outcomes such as myocardial infarction or death. This review summarizes current evidence for many applied ischaemia treatments documented to modify angina and comments on available evidence relating to improvement in cardiovascular outcomes.
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Affiliation(s)
- David E Winchester
- North Florida/South Georgia Veterans Health System, Gainesville, FL, USA; Division of Cardiovascular Medicine, University of Florida, 1600 S.W. Archer Rd., PO Box 100277, Gainesville, FL 32610-0277, USA
| | - Carl J Pepine
- Division of Cardiovascular Medicine , University of Florida , 1600 S.W. Archer Rd., PO Box 100277, Gainesville, FL 32610-0277 , USA
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27
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Abstract
Classical angina refers to typical substernal discomfort triggered by effort or emotions, relieved with rest or nitroglycerin. The well-accepted pathogenesis is an imbalance between oxygen supply and demand. Goals in therapy are improvement in quality of life by limiting the number and severity of attacks, protection against future lethal events, and measures to lower the burden of risk factors to slow disease progression. New pathophysiological data, drugs, as well as conceptual and technological advances have improved patient care over the past decade. Behavioral changes to improve diets, increase physical activity, and encourage adherence to cardiac rehabilitation programs, are difficult to achieve but are effective.
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Affiliation(s)
- Richard Kones
- The Cardiometabolic Research Institute, 8181 Fannin Street, Unit 314, Houston, TX 77054, USA.
| | - Umme Rumana
- The Cardiometabolic Research Institute, 8181 Fannin Street, Unit 314, Houston, TX 77054, USA
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28
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Singh S, Schwarz K, Horowitz J, Frenneaux M. Cardiac energetic impairment in heart disease and the potential role of metabolic modulators: a review for clinicians. ACTA ACUST UNITED AC 2015; 7:720-8. [PMID: 25518045 DOI: 10.1161/circgenetics.114.000221] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cardiac energetic impairment is a frequent finding in patients with both inherited and acquired diseases of heart muscle. In this review the mechanisms of energy generation in the healthy heart and their disturbances in heart muscle diseases are described. Therapeutic agents targeted at correcting cardiac energetic impairment are discussed.
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Affiliation(s)
- Satnam Singh
- From the Department of Cardiovascular Medicine, University of Aberdeen, Aberdeen, United Kingdom (S.S., K.S., M.F.); and Cardiology Unit, The Queen Elizabeth Hospital, Adelaide, Australia (J.H.)
| | - Konstantin Schwarz
- From the Department of Cardiovascular Medicine, University of Aberdeen, Aberdeen, United Kingdom (S.S., K.S., M.F.); and Cardiology Unit, The Queen Elizabeth Hospital, Adelaide, Australia (J.H.)
| | - John Horowitz
- From the Department of Cardiovascular Medicine, University of Aberdeen, Aberdeen, United Kingdom (S.S., K.S., M.F.); and Cardiology Unit, The Queen Elizabeth Hospital, Adelaide, Australia (J.H.)
| | - Michael Frenneaux
- From the Department of Cardiovascular Medicine, University of Aberdeen, Aberdeen, United Kingdom (S.S., K.S., M.F.); and Cardiology Unit, The Queen Elizabeth Hospital, Adelaide, Australia (J.H.).
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29
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Chrusciel P, Rysz J, Banach M. Defining the role of trimetazidine in the treatment of cardiovascular disorders: some insights on its role in heart failure and peripheral artery disease. Drugs 2015; 74:971-80. [PMID: 24902800 PMCID: PMC4061463 DOI: 10.1007/s40265-014-0233-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Piotr Chrusciel
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Zeromskiego 113, 90-549 Lodz, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension, and Family Medicine, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Zeromskiego 113, 90-549 Lodz, Poland
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30
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Zhang N, Lei J, Liu Q, Huang W, Xiao H, Lei H. The Effectiveness of Preoperative Trimetazidine on Myocardial Preservation in Coronary Artery Bypass Graft Patients: A Systematic Review and Meta-Analysis. Cardiology 2015; 131:86-96. [DOI: 10.1159/000375289] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 12/19/2014] [Indexed: 11/19/2022]
Abstract
Background: Coronary artery bypass grafting (CABG) is a key and effective surgical treatment modality for coronary artery disease. Unfortunately, ischemia-reperfusion injury during and after CABG can lead to reversible and irreversible myocardial damage. Trimetazidine [1-(2,3,4-trimethoxybenzyl)piperazine dihydrochloride] is a metabolic anti-ischemic agent with demonstrated cardioprotective effects; however, its effects with respect to myocardial preservation in CABG patients remain unclear. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to investigate the effectiveness of myocardial preservation of preoperative trimetazidine therapy in CABG patients by assessing the postoperative levels of several blood-based biochemical markers of myocardial injury, including creatine kinase (CK), creatine kinase-muscle and brain (CK-MB), creatine phosphokinase (CPK), troponin T (TnT) and troponin I (TnI). The RCTs were classified into two subgroup analyses by the timing of sample collection (either ≤12 or >12 h after CABG). Results: Six RCTs were finally included in the meta-analysis. The pooled effect sizes showed significantly lower postoperative levels of CK, CK-MB, TnT and TnI in the trimetazidine-treated CABG patients relative to control CABG patients. However, there were no significant differences in the postoperative CPK levels between trimetazidine-treated CABG patients relative to control CABG patients. In both the ≤12 and >12 h post-CABG subgroup analyses, significant differences in CK, CK-MB, TnT and TnI were detected between the trimetazidine-treated CABG patients relative to control CABG patients. Conclusions: Preoperative trimetazidine therapy appears to have a positive effect on myocardial preservation in CABG patients.
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Grajek S, Michalak M. The effect of trimetazidine added to pharmacological treatment on all-cause mortality in patients with systolic heart failure. Cardiology 2015; 131:22-9. [PMID: 25832112 DOI: 10.1159/000375288] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 12/23/2014] [Indexed: 11/19/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Stefan Grajek
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
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Stable ischemic heart disease. Cardiol Clin 2014; 32:333-51. [PMID: 25091962 DOI: 10.1016/j.ccl.2014.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Classical angina refers to typical substernal discomfort triggered by effort or emotions, relieved with rest or nitroglycerin. The well-accepted pathogenesis is an imbalance between oxygen supply and demand. Goals in therapy are improvement in quality of life by limiting the number and severity of attacks, protection against future lethal events, and measures to lower the burden of risk factors to slow disease progression. New pathophysiological data, drugs, as well as conceptual and technological advances have improved patient care over the past decade. Behavioral changes to improve diets, increase physical activity, and encourage adherence to cardiac rehabilitation programs, are difficult to achieve but are effective.
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Soukoulis V, Boden WE, Smith SC, O'Gara PT. Nonantithrombotic medical options in acute coronary syndromes: old agents and new lines on the horizon. Circ Res 2014; 114:1944-58. [PMID: 24902977 PMCID: PMC4083844 DOI: 10.1161/circresaha.114.302804] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute coronary syndromes (ACS) constitute a spectrum of clinical presentations ranging from unstable angina and non-ST-segment elevation myocardial infarction to ST-segment myocardial infarction. Myocardial ischemia in this context occurs as a result of an abrupt decrease in coronary blood flow and resultant imbalance in the myocardial oxygen supply-demand relationship. Coronary blood flow is further compromised by other mechanisms that increase coronary vascular resistance or reduce coronary driving pressure. The goals of treatment are to decrease myocardial oxygen demand, increase coronary blood flow and oxygen supply, and limit myocardial injury. Treatments are generally divided into disease-modifying agents or interventions that improve hard clinical outcomes and other strategies that can reduce ischemia. In addition to traditional drugs such as β-blockers and inhibitors of the renin-angiotensin-aldosterone system, newer agents have expanded the number of molecular pathways targeted for treatment of ACS. Ranolazine, trimetazidine, nicorandil, and ivabradine are medications that have been shown to reduce myocardial ischemia through diverse mechanisms and have been tested in limited fashion in patients with ACS. Attenuating the no-reflow phenomenon and reducing the injury compounded by acute reperfusion after a period of coronary occlusion are active areas of research. Additionally, interventions aimed at ischemic pre- and postconditioning may be useful means by which to limit myocardial infarct size. Trials are also underway to examine altered metabolic and oxygen-related pathways in ACS. This review will discuss traditional and newer anti-ischemic therapies for patients with ACS, exclusive of revascularization, antithrombotic agents, and the use of high-intensity statins.
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Affiliation(s)
- Victor Soukoulis
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.S., P.T.O.); Division of Cardiology, Department of Medicine, Albany Stratton Veteran's Affairs Medical Centre and Albany Medical College, NY (W.E.B.); and Division of Cardiology, University of North Carolina, Chapel Hill (S.C.S.)
| | - William E Boden
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.S., P.T.O.); Division of Cardiology, Department of Medicine, Albany Stratton Veteran's Affairs Medical Centre and Albany Medical College, NY (W.E.B.); and Division of Cardiology, University of North Carolina, Chapel Hill (S.C.S.)
| | - Sidney C Smith
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.S., P.T.O.); Division of Cardiology, Department of Medicine, Albany Stratton Veteran's Affairs Medical Centre and Albany Medical College, NY (W.E.B.); and Division of Cardiology, University of North Carolina, Chapel Hill (S.C.S.)
| | - Patrick T O'Gara
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.S., P.T.O.); Division of Cardiology, Department of Medicine, Albany Stratton Veteran's Affairs Medical Centre and Albany Medical College, NY (W.E.B.); and Division of Cardiology, University of North Carolina, Chapel Hill (S.C.S.).
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Ussher JR, Keung W, Fillmore N, Koves TR, Mori J, Zhang L, Lopaschuk DG, Ilkayeva OR, Wagg CS, Jaswal JS, Muoio DM, Lopaschuk GD. Treatment with the 3-ketoacyl-CoA thiolase inhibitor trimetazidine does not exacerbate whole-body insulin resistance in obese mice. J Pharmacol Exp Ther 2014; 349:487-96. [PMID: 24700885 DOI: 10.1124/jpet.114.214197] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
There is a growing need to understand the underlying mechanisms involved in the progression of cardiovascular disease during obesity and diabetes. Although inhibition of fatty acid oxidation has been proposed as a novel approach to treat ischemic heart disease and heart failure, reduced muscle fatty acid oxidation rates may contribute to the development of obesity-associated insulin resistance. Our aim was to determine whether treatment with the antianginal agent trimetazidine, which inhibits fatty acid oxidation in the heart secondary to inhibition of 3-ketoacyl-CoA thiolase (3-KAT), may have off-target effects on glycemic control in obesity. We fed C57BL/6NCrl mice a high-fat diet (HFD) for 10 weeks before a 22-day treatment with the 3-KAT inhibitor trimetazidine (15 mg/kg per day). Insulin resistance was assessed via glucose/insulin tolerance testing, and lipid metabolite content was assessed in gastrocnemius muscle. Trimetazidine-treatment led to a mild shift in substrate preference toward carbohydrates as an oxidative fuel source in obese mice, evidenced by an increase in the respiratory exchange ratio. This shift in metabolism was accompanied by an accumulation of long-chain acyl-CoA and a trend to an increase in triacylglycerol content in gastrocnemius muscle, but did not exacerbate HFD-induced insulin resistance compared with control-treated mice. It is noteworthy that trimetazidine treatment reduced palmitate oxidation rates in the isolated working mouse heart and neonatal cardiomyocytes but not C2C12 skeletal myotubes. Our findings demonstrate that trimetazidine therapy does not adversely affect HFD-induced insulin resistance, suggesting that treatment with trimetazidine would not worsen glycemic control in obese patients with angina.
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Affiliation(s)
- John R Ussher
- Cardiovascular Research Centre, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada (J.R.U., W.K., N.F., J.M., L.Z., D.G.L., C.S.W., J.S.J., G.D.L.); and Sarah W. Stedman Nutrition and Metabolism Center (T.R.K., O.R.I., D.M.M.), Department of Medicine (T.R.K., O.R.I., D.M.M.), Department of Pharmacology and Cancer Biology (D.M.M.), Duke University, Durham, North Carolina
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Henry TD, Satran D, Jolicoeur EM. Treatment of refractory angina in patients not suitable for revascularization. Nat Rev Cardiol 2013; 11:78-95. [DOI: 10.1038/nrcardio.2013.200] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
INTRODUCTION Management of chronic angina has evolved dramatically in the last few decades with several options for pharmacotherapy outlined in various evidence-based guidelines. AREAS COVERED There is a growing list of drugs that are currently being investigated for treatment of chronic angina. These also include several herbal medications, which are now being scientifically evaluated as potential alternative or even adjunctive therapy for angina. Gene- and cell-based therapies have opened yet another avenue for management of chronic refractory angina in 'no-option' patients who are not candidates for either percutaneous or surgical revascularization and are on optimal medical therapy. An extensive review of literature using PUBMED, Cochrane database, clinical trial databases of the USA and European Union was done and summarized in this review. This review will attempt to discuss the traditional as well as novel therapeutic agents for angina. EXPERT OPINION Several pharmacological and non-pharmacological therapeutic options are now available for treatment and management of chronic refractory angina. Renewed interest in traditional therapies and cell- and gene-based modalities with targeted drug delivery systems will open the doors for personalized therapy for patients with chronic refractory angina.
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Affiliation(s)
- Ashish K Gupta
- University of Florida, Division of Cardiovascular Medicine , 1600 SW Archer Road, P.O. Box 100277, Gainesville, FL 32610-0277 , USA
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Novikova MV, Glezer MG. TRIMETAZIDINE MR EFFECTS ON THE PARAMETERS OF 24-HOUR ELECTROCARDIOGRAM MONITORING AND HEART RATE VARIABILITY. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2013. [DOI: 10.15829/1728-8800-2013-5-68-74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Aim. To assess the effects of the four-month trimetazidine MR therapy on the parameters of 24-hour electrocardiogram (ECG) monitoring and heart rate variability (HRV) in patients with stable coronary heart disease (CHD).Material and methods. This prospective, non-randomised study, with the inclusion of 66 consecutive patients who had stable CHD and stable stress test results, investigated the effects of trimetazidine MR therapy on the parameters of 24-hour ECG monitoring and HRV.Results. Trimetazidine MR did not markedly affect the 24-hour, daytime, or nighttime levels of heart rate. Trimetazidine MR therapy was not associated with any substantial changes in frequency and time-domain HRV parameters or in the incidence of cardiac arrhythmias. However, there was a significant reduction in the number of patients with ST segment depression (from 66,7% to 43,8%; p<0,001) and in the duration of ischemic episodes (from 10 (6,2;21) minutes to 7,42 (5;12,3) minutes (p=0,025)).Conclusion. Adding trimetazidine MR to the treatment of patients with stable CHD provides an additional beneficial antiischemic effect.
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Affiliation(s)
- M. V. Novikova
- Moscow City Healthcare Department, City Clinical Hospital No. 59
| | - M. G. Glezer
- Moscow City Healthcare Department, City Clinical Hospital No. 59;
I.M. Sechenov First Moscow State Medical University, Moscow
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Rider OJ, Tyler DJ. Clinical implications of cardiac hyperpolarized magnetic resonance imaging. J Cardiovasc Magn Reson 2013; 15:93. [PMID: 24103786 PMCID: PMC3819516 DOI: 10.1186/1532-429x-15-93] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 10/01/2013] [Indexed: 02/01/2023] Open
Abstract
Alterations in cardiac metabolism are now considered a cause, rather than a result, of cardiac disease. Although magnetic resonance spectroscopy has allowed investigation of myocardial energetics, the inherently low sensitivity of the technique has limited its clinical application in the study of cardiac metabolism. The development of a novel hyperpolarization technique, based on the process of dynamic nuclear polarization, when combined with the metabolic tracers [1-(13)C] and [2-(13)C] pyruvate, has resulted in significant advances in the understanding of real time myocardial metabolism in the normal and diseased heart in vivo. This review focuses on the changes in myocardial substrate selection and downstream metabolism of hyperpolarized 13C labelled pyruvate that have been shown in diabetes, ischaemic heart disease, cardiac hypertrophy and heart failure in animal models of disease and how these could translate into clinical practice with the advent of clinical grade hyperpolarizer systems.
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Affiliation(s)
- Oliver J Rider
- University of Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Oxford Metabolic Imaging Group, University of Oxford, Oxford, UK
| | - Damian J Tyler
- Oxford Metabolic Imaging Group, University of Oxford, Oxford, UK
- Department of Physiology, Anatomy and Genetics, University of Oxford, Parks Road, Oxford, OX1 3PT, UK
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012. [PMID: 23182125 DOI: 10.1016/j.jacc.2012.07.013] [Citation(s) in RCA: 1227] [Impact Index Per Article: 102.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Parker JD, Parker JO. Stable angina pectoris: the medical management of symptomatic myocardial ischemia. Can J Cardiol 2012; 28:S70-80. [PMID: 22424287 DOI: 10.1016/j.cjca.2011.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2009] [Revised: 11/03/2011] [Accepted: 11/03/2011] [Indexed: 12/19/2022] Open
Abstract
Coronary artery disease (CAD) remains an important cause of morbidity and mortality and is a serious public health problem. Over the last 4 decades there have been dramatic advances in the both the prevention and treatment of CAD. The management of CAD was revolutionized by the development of effective surgical and percutaneous revascularization techniques. In this review we discuss the importance of the medical management of symptomatic, stable angina. Medical management approaches to both the treatment and prevention of symptomatic myocardial ischemia are summarized. In Canada, organic nitrates, β-adrenergic blocking agents, and calcium channel antagonists have been available for the therapy of angina for more than 25 years. All 3 classes are of proven benefit in the improvement of symptoms and exercise capacity in patients with stable angina. Although there is no clear first choice within these classes of anti-anginal agents, the presence of prior or concurrent conditions (for example, prior myocardial infarction and/or hypertension) plays an important role in the choice of anti-anginal class in individual patients. For some patients, combinations of different anti-anginal agents can be effective; however it is recommended that this approach be individualized. Although not currently available in Canada, other classes of anti-anginal agents have been developed; their mechanism of action and clinical efficacy is discussed. Patients with stable angina have an excellent prognosis. Patients in this category who obtain relief from symptomatic myocardial ischemia may do well without invasive intervention.
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Affiliation(s)
- John D Parker
- The Mount Sinai and University Health Network Hospitals, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Rosen SD. From heart to brain: the genesis and processing of cardiac pain. Can J Cardiol 2012; 28:S7-19. [PMID: 22424286 DOI: 10.1016/j.cjca.2011.09.010] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 09/15/2011] [Accepted: 09/15/2011] [Indexed: 01/12/2023] Open
Abstract
Angina pectoris is important because of its association with heart disease and risk of death. Historically after Heberden's account of angina in 1772, the association of pain with coronary artery disease quickly followed. Within a few years, Burns suggested an etiological role for ischemia. Subsequently, theories of differential myocardial stretch dominated thinking until Lewis' chemical hypothesis in 1932, in which the local release of chemical substances during ischemia was seen as the cause of pain. This review considers how ischemia at the tissue level triggers activation of afferent nociceptive pain fibres. The afferent projections of sympathetic and vagal afferent fibres are described, with a number of methodologies cited (eg, injection of pseudorabies virus into the heart with mapping of the retrograde viral transport pathways; and elevation of neuronal c-fos synthesis in brain regions activated by capsaicin application to the heart). Our own functional neuroimaging studies of angina are also reviewed. There are 2 intriguing features of angina. The first is the poor correlation between symptoms and extent of coronary disease. The spectrum ranges from entirely silent myocardial ischemia to that of a functional pain syndrome--the 'sensitive heart'--of cardiac syndrome X. An even more difficult aspect is the wide variability in symptoms experienced by an individual patient. A new paradigm is presented which, besides considering myocardial oxygen supply/demand imbalance, also draws insights from the broader field of pain research. Neuromodulation applies at multiple levels of the neuraxis--peripheral nerves, spinal cord, and brain--and it invites exploitation, whether pharmacological or electrical, for the benefit of the cardiac patient in pain.
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Affiliation(s)
- Stuart D Rosen
- National Heart and Lung Institute, Imperial College, London, United Kingdom.
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42
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Management of Patients With Refractory Angina: Canadian Cardiovascular Society/Canadian Pain Society Joint Guidelines. Can J Cardiol 2012; 28:S20-41. [DOI: 10.1016/j.cjca.2011.07.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 07/21/2011] [Accepted: 07/21/2011] [Indexed: 11/24/2022] Open
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Gayet JL, Paganelli F, Cohen-Solal A. Update on the medical treatment of stable angina. Arch Cardiovasc Dis 2011; 104:536-44. [DOI: 10.1016/j.acvd.2011.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 08/05/2011] [Accepted: 08/08/2011] [Indexed: 01/30/2023]
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Abstract
Advances in pharmacotherapy for stable angina have produced a wide choice of drugs with various mechanisms of action, potentially enabling individualized, patient-specific treatment strategies to be developed. In this Review, the various treatment options for patients with stable angina are discussed. Data from randomized, clinical trials of established and novel drugs are reviewed, with particular emphasis on the proposed mechanisms of action, benefits of therapy, and adverse-effect profiles. The role of coronary revascularization in conjunction with optimal medical therapy as a treatment strategy is discussed, although drug therapy might reduce the need for prompt revascularization if the procedure is being considered solely for the purpose of alleviating angina. Finally, trials to investigate stimulation of angiogenesis using growth-factor, gene, and cell therapy are used to illustrate the challenges of chemically inducing the growth of adequate, durable blood vessels.
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Affiliation(s)
- Bernard R Chaitman
- Department of Medicine, Division of Cardiology, Saint Louis University School of Medicine, 1034 South Brentwood Boulevard, Suite 1550, St Louis, MO 63117, USA.
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46
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Kones R. Recent advances in the management of chronic stable angina II. Anti-ischemic therapy, options for refractory angina, risk factor reduction, and revascularization. Vasc Health Risk Manag 2010; 6:749-74. [PMID: 20859545 PMCID: PMC2941787 DOI: 10.2147/vhrm.s11100] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Indexed: 12/19/2022] Open
Abstract
The objectives in treating angina are relief of pain and prevention of disease progression through risk reduction. Mechanisms, indications, clinical forms, doses, and side effects of the traditional antianginal agents - nitrates, β-blockers, and calcium channel blockers - are reviewed. A number of patients have contraindications or remain unrelieved from anginal discomfort with these drugs. Among newer alternatives, ranolazine, recently approved in the United States, indirectly prevents the intracellular calcium overload involved in cardiac ischemia and is a welcome addition to available treatments. None, however, are disease-modifying agents. Two options for refractory angina, enhanced external counterpulsation and spinal cord stimulation (SCS), are presented in detail. They are both well-studied and are effective means of treating at least some patients with this perplexing form of angina. Traditional modifiable risk factors for coronary artery disease (CAD) - smoking, hypertension, dyslipidemia, diabetes, and obesity - account for most of the population-attributable risk. Individual therapy of high-risk patients differs from population-wide efforts to prevent risk factors from appearing or reducing their severity, in order to lower the national burden of disease. Current American College of Cardiology/American Heart Association guidelines to lower risk in patients with chronic angina are reviewed. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial showed that in patients with stable angina, optimal medical therapy alone and percutaneous coronary intervention (PCI) with medical therapy were equal in preventing myocardial infarction and death. The integration of COURAGE results into current practice is discussed. For patients who are unstable, with very high risk, with left main coronary artery lesions, in whom medical therapy fails, and in those with acute coronary syndromes, PCI is indicated. Asymptomatic patients with CAD and those with stable angina may defer intervention without additional risk to see if they will improve on optimum medical therapy. For many patients, coronary artery bypass surgery offers the best opportunity for relieving angina, reducing the need for additional revascularization procedures and improving survival. Optimal medical therapy, percutaneous coronary intervention, and surgery are not competing therapies, but are complementary and form a continuum, each filling an important evidence-based need in modern comprehensive management.
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Affiliation(s)
- Richard Kones
- Cardiometabolic Research Institute, Houston, Texas 77055, USA.
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Affiliation(s)
- Renjith Antony
- Scottish Advanced Heart Failure Service, Golden Jubilee National Hospital, Clydebank, West Dunbartonshire G81 4HX, UK
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Rosano GMC, Vitale C, Volterrani M. Heart rate in ischemic heart disease. The innovation of ivabradine: more than pure heart rate reduction. Adv Ther 2010; 27:202-10. [PMID: 20495895 DOI: 10.1007/s12325-010-0030-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Indexed: 10/19/2022]
Abstract
A wealth of data suggests that heart rate (HR) is an independent predictor of cardiovascular and all-cause mortality in men and women of all ages with and without cardiovascular disease. Data gathered from clinical trials suggest that HR reduction is an important mechanism of benefit of HR-lowering drugs. A high HR has direct detrimental effects not only on myocardial ischemia but also on the progression of atherosclerosis, ventricular arrhythmias, and on left ventricular function. The risk increases with HR >60 b.p.m. Ivabradine, a drug that slows HR though an effect on the If channels, has been approved for the control of myocardial ischemia in patients with coronary artery disease intolerant to beta-blockers. More recently, the indication of ivabradine has been extended for use in association with beta-blockers in patients with coronary artery disease. The effects of ivabradine on myocardial ischemia are greater than those predicted by pure HR reduction with beta-blockers, suggesting additional mechanisms of action.
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Affiliation(s)
- Itsik Ben-Dor
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
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