Evaluation of trimetazidine in angina pectoris by echocardiography and radionuclide angiography: a meta-analysis of randomized, controlled trials

The Impact of Trimetazidine on Cardiac Fibrosis, Inflammation, and Function in Ischemic Cardiomyopathy Patients

BACKGROUND

Previous studies have shown that Trimetazidine (TMZ) improves vascular endothelial function and reduces the inflammatory process progression. However, limited data have been available regarding its effects on myocardial fibrosis following ischemia and causing left ventricular dysfunction.

PURPOSE

To investigate the impact of TMZ adjuvant therapy for ischemic cardiomyopathy (ICM) on cardiac fibrosis, vascular endothelial function, inflammation, and myocardial functions.

METHODS

This randomized, double-blind controlled clinical trial included 48 patients (aged 59.4 ± 9 years) with ICM who were randomly assigned to two groups: TMZ 35 mg twice daily and placebo in addition to conventional ICM medications. All patients received the tablets for 3 months. Both groups were then compared in terms of connective tissue growth factor (CTGF), endothelin-1 (ET-1), tumor necrosis factor-alpha (TNF-α), and some echocardiographic indices, weekly angina attacks and nitrate consumption before and after treatment.

RESULTS

No significant differences between CTGF, ET-1, and TNF-α levels, in addition to some echocardiographic indices, were observed between both groups before treatment. After treatment, the TMZ group had significantly lower ET-1 than the placebo group, with both groups exhibiting a substantial decrease in TNF-α and CTGF. The TMZ group had lower mean ± SD levels for TNF-α and CTGF and showed significant improvement in echocardiographic indices and weekly angina attacks after treatment.

CONCLUSION

Adjunctive TMZ therapy for ICM effectively improved vascular endothelial function and reduced inflammation. Furthermore, our exploratory findings may be used to provide new information on the potential effects of TMZ on myocardial fibrosis by downregulating CTGF.

Trimetazidine and Bisoprolol to Treat Angina in Symptomatic Patients: Post Hoc Analysis From the CHOICE-2 Study

Introduction

Angina is the cardinal symptom of chronic coronary syndrome (CCS), which is the leading cause of death worldwide. As such, the control of angina is important. The current guidelines recommend beta blockers (BB) or calcium channel blockers to reduce angina, yet many patients with stable angina remain symptomatic. It has been suggested that combining trimetazidine (TMZ), an anti-ischemic agent, with a BB is beneficial for symptomatic patients. Bisoprolol, a BB, is often used to treat patients with CCS, yet no data are currently available regarding the efficacy of bisoprolol combined with TMZ in patients who remain symptomatic despite receiving bisoprolol.

Methods

The aim of this post-hoc analysis of the CHOICE-2 study was to evaluate the efficacy and safety of TMZ 35 mg twice daily in combination with different bisoprolol doses in symptomatic patients with stable angina patients receiving hemodynamic therapy in a real-world clinical setting.

Results

This analysis involved 221 patients (mean [± standard deviation] age 64.8 ± 8.9 years) with stable angina. The mean number of weekly angina episodes gradually fell from 6.2 ± 5.3 at inclusion (M0) to 1.5 ± 1.9 at 6 months after treatment initiation (M6) with combined TMZ–bisoprolol therapy (P < 0.001). The number of patients assessed to be angina-free increased almost sixfold from 5.4% (12/221) at M0 to 33.9% (74/221) at M6. Exercise capacity improved, as measured by walking distance, from 308 ± 207 m at M0 to 497 ± 253 m at M6 (P < 0.05). The number of patients with Canadian Cardiovascular Society class 1 angina increased by tenfold during the study, whereas those with class 3 angina decreased by threefold.

Conclusion

The TMZ–bisoprolol combination is a rapidly effective treatment for reducing the frequency of angina attacks and the use of short-acting nitrates in patients with stable angina in a real-world clinical setting. The benefits of this combination therapy was observed as early as 2 weeks after treatment initiation and the treatment was well tolerated.

Trial Registration

ISRCTN identifier: ISRCTN65209863

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Meta-analysis of trimetazidine treatment for cardiomyopathy

To explore the effect of trimetazidine (TMZ) in cardiomyopathy treatment. Literatures, related with TMZ treatment for cardiomyopathy, were retrieved between 1990 and February 2018 in the Pubmed, Embase, and Cochrane Library systems. Cardiopulmonary exercise testing [resting heart rate (RHR), peak heart rate (PHR), peak systolic blood pressure (PSBP), and resting systolic blood pressure (RSBP)] and echocardiographic results [left ventricular ejection fraction (LVEF), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV), systolic wall thickening score index (SWTSI), left ventricular end-systolic diameter (LVESD), and left ventricular end-diastolic diameter (LVEDD)] were merged to detect the publication bias. Total 898 patients with cardiomyopathy were divided into two groups: TMZ-treated group (n=456) and control group (n=442). There was no difference in the improvement of cardiomyopathy between the TMZ and control group. No publication bias was shown for PHR (t= 0.9791, P=0.5067). There were significant differences in LVEF, LVESV, SWTSI, LVESD, and LVEDD between the TMZ group and the control group. TMZ-treatment significantly increased the level of LVEF (95% confidence interval (CI): 5.46-7.84, P<0.001), and reduced the level of LVESV (95% CI: -18.73 to -7.77, P<0.001), SWTSI (95% CI: -0.47 to -0.15, Z = -3.85, P=0.001), LVESD (95% CI: -1.09 to -0.08, P<0.001), and LVEDD (95% CI: -0.55 to -0.26, P=0.023). There was no publication bias except for LVEDV (t = 2.5456, P=0.0438). TMZ is effective for cardiomyopathy treatment and worth to popularize in clinic.

Trimetazidine and Other Metabolic Modifiers

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Trimetazidine in Practice: Review of the Clinical and Experimental Evidence

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 I_f 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.

The Role of Ivabradine and Trimetazidine in the New ESC HF Guidelines

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.

The Effectiveness of Preoperative Trimetazidine on Myocardial Preservation in Coronary Artery Bypass Graft Patients: A Systematic Review and Meta-Analysis

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.

Chronic treatment with trimetazidine after discharge reduces the incidence of restenosis in patients who received coronary stent implantation: a 1-year prospective follow-up study

BACKGROUND

The incidence of stent restenosis (SR) has risen with as more patients are being treated with drug-eluting stents (DESs). Trimetazidine has multiple favorable effects on the cardiovascular system. Here, we aimed to evaluate whether chronic treatment with trimetazidine reduced the incidence of SR.

METHODS

From January 2009 to December 2011 at Chinese PLA General Hospital, 768 patients were enrolled and randomized into the trimetazidine treatment group (TG, n = 384) and control group (CG, n = 384). After DES implantation, all patients were treated with regular medication. In the TG, trimetazidine was administrated at 20mg tid for at least 30days. All patients received follow-up angiography 9-13 months after discharge. Major adverse cardiac and cerebrovascular events (MACCEs) were recorded.

RESULTS

Six hundred thirty-five patients were included in the final analysis (TG, n = 312; CG, n = 323). SR occurred in 49 (7.7%) patients. The TG had a lower incidence of SR compared to the CG (4.2% vs. 11.1%, p = 0.001). At the 30-day follow-up, the TG exhibited a higher left ventricular ejection fraction than the CG (65.4 ± 10.7 vs. 63.1 ± 10.4, p = 0.006). The incidence of MACCEs was also lower in the TG at the 1-year follow-up (6.1% vs. 10.8%, p = 0.032). Further multivariate analysis revealed that trimetazidine treatment was a predictor for SR (OR: 0.376; 95% CI: 0.196-0.721; p = 0.003).

CONCLUSIONS

Trimetazidine treatment effectively reduced the incidence of SR and MACCEs after DES implantation at the 1-year follow-up.

Trimetazidine and cardioprotection: facts and perspectives

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

Energy metabolism in cardiac remodeling and heart failure

Fatty acids are the main substrates used by mitochondria to provide myocardial energy under normal conditions. During heart remodeling, however, the fuel preference switches to glucose. In the earlier stages of cardiac remodeling, changes in energy metabolism are considered crucial to protect the heart from irreversible damage. Furthermore, low fatty acid oxidation and the stimulus for glycolytic pathway lead to lipotoxicity, acidosis, and low adenosine triphosphate production. While myocardial function is directly associated with energy metabolism, the metabolic pathways could be potential targets for therapy in heart failure.