Acute effects of trimetazidine on ergometric parameters in effort angina

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

BACKGROUND

The objective of this meta-analysis was to evaluate the efficacy of the metabolic agent trimetazidine (TMZ) as monotherapy in the treatment of stable angina pectoris, from echocardiography and radionuclide angiography data.

HYPOTHESIS

Treatment with TMZ proved to be as effective as other first-line antianginal agents for coronary patients, and it provided additional efficacy in combination with hemodynamic agents.

METHODS

A search of the literature published between 1965 and 2008 was performed on the MEDLINE and EMBASE databases. Only randomized, controlled trials were included in this meta-analysis. Patients had to be treated for at least 2 weeks with data on the following 4 parameters at baseline and at the end of the treatment period: left ventricular ejection fraction (LVEF), LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), and wall motion score index (WMSI). The quality of the trials was assessed by the Jadad score.

RESULTS

Eleven clinical studies meeting our criteria were analyzed. Results showed that TMZ significantly improved LVEF, with a mean increase of 6.88% (95% confidence interval [CI]: 5.50-8.25), and significantly reduced LVESV by 11.58 mL (95% CI: 5.79-17.37) and WMSI by 0.23 (95% CI: 0.07-0.38). Changes in LVEDV were variable. In both the long term and the short term, TMZ can improve LV function. The efficacy was unchanged in patients with diabetes mellitus.

CONCLUSIONS

This meta-analysis confirmed the efficacy of TMZ monotherapy in improving LV function compared with placebo.

Efficacy and tolerability of trimetazidine in stable angina: a meta-analysis of randomized, double-blind, controlled trials

OBJECTIVE

The objective of this meta-analysis was to evaluate the efficacy and tolerance of the metabolic agent trimetazidine (TMZ), both in monotherapy and in combination with other antianginal agents, in the treatment of stable angina pectoris. A search of literature published between 1985 and 2001 was performed on computerized databases (MEDLINE and EMBASE).

METHODS

Only double-blind, randomized, controlled trials were included in this meta-analysis. Patients had to be treated for at least 2 weeks. Four parameters were selected, one clinical parameter (number of weekly angina attacks) and three ergometric parameters (time to 1 mm ST-segment depression, total work and exercise duration at peak exercise). They were evaluated at baseline and at the end of the treatment period.The quality of the trials was assessed on specific methodological criteria. Standard statistical methods, pooled odds ratio and 95% confidence intervals for subjective symptoms and pooled z and P for objective symptoms, were used.

RESULTS

Twelve clinical studies meeting our criteria were analyzed. Results showed that TMZ significantly reduced the number of weekly angina attacks in coronary patients and improved time to 1 mm segment depression and total work at peak exercise, while exercise duration at peak exercise showed a trend toward improvement (P = 0.09).

CONCLUSION

This meta-analysis confirms the efficacy of TMZ in the treatment of stable angina, compared with placebo or conventional antianginal agent, as well as in monotherapy or in combination with conventional antianginal agents. TMZ is well tolerated in monotherapy as well as in combination.

Metabolic modulation and optimization of energy consumption in heart failure

Chronic heart failure (CHF) is a common and disabling syndrome with a poor prognosis. It is a major and increasing public health problem. Angiotensin-converting enzyme inhibitors, diuretics, and digitalis are the standards treatments for CHF. Other drugs, such as beta-blockers, spironolactone, calcium antagonists, vasodilators, and antiarrhythmic agents are used to counteract the progression of the syndrome or to improve the hemodynamic profile. Despite optimum treatment with neurohumoral antagonists, prognosis of CHF remains poor; the patients complain of persistent reductions in their exercise capacity and quality of life. Fatigue and shortness of breath, two common and disabling symptoms in patient with CHF, are relatively independent from hemodynamic and neuroendocrine changes, although they seem to be related to the impairment of peripheral muscle metabolism and energetic phosphate production. Therefore, CHF is a complex metabolic syndrome in which the metabolism of cardiac and peripheral muscles is impaired and novel therapeutic strategies have been aimed at positive modulation with compounds such as carnitine, trimetazidine, and ranolazine.

Metabolic approaches to the treatment of ischemic heart disease: the clinicians' perspective

This review article discusses pharmacological approaches to optimizing myocardial metabolism during ischemia. Fatty acids are the main fuel for the healthy heart, with a lesser contribution coming from the oxidation of glucose and lactate. Myocardial ischaemia dramatically alters fuel metabolism, causing an accelerated rate of glucose conversion to lactate and a switch from lactate uptake by the heart to lactate production. This causes a dramatic disruption in cell homeostasis (e.g. lactate accumulation and a decrease in pH and ATP). Paradoxically, moderately ischemic tissue (approximately 50% of normal flow) continues to derive most of its energy (50-70%) from the oxidation of fatty acids despite a high rate of lactate production. This ischaemia-induced disruption in cardiac metabolism can be minimized by metabolic agents that reduce fatty acid oxidation and increase the combustion of glucose and lactate, resulting in clinical benefit to the ischemic patient. Agents that inhibit fatty acid beta-oxidation, such as ranolazine and trimetazidine, have proven to be effective in the treatment of stable angina. Treatment of acute myocardial infarction patients with an infusion of the glucose-insulin-potassium, which results in suppression of myocardial fatty acid oxidation and greater glucose combustion, has proven effective in reducing mortality. These metabolic therapies are free of direct hemodynamic or chronotropic effects, and thus are well positioned for use alongside traditional agents such as beta-adrenergic receptor antagonists or calcium channel antagonists.

Intracoronary trimetazidine does not improve recovery of regional function in a porcine model of repeated ischemia

We evaluated the effect of trimetazidine (TMZ) on recovery of regional cardiac function in anesthetized open-chest pigs, subjected to fifteen 2-minute occlusions of the left anterior descending coronary artery, separated by 2 minutes of reperfusion and a 120-minute recovery period. Regional myocardial function was evaluated by sonomicrometry-derived segment lengthening and the area enclosed by the left ventricular pressure-segment length loop (external work, EW) in animals, which received either an intracoronary infusion of TMZ (33 micrograms/kg/min, n = 6) or saline (1 ml/min, n = 7), starting 15 minutes before the first occlusion and ending 2 minutes after the 15th occlusion. In addition, myocardial malondialdehyde production to evaluate oxygen free radical production, oxygen consumption, and the ATP, ADP, and AMP content, as well as the energy charge, were determined at regular time intervals. In control pigs the sequences of occlusion-reperfusion did not affect systemic hemodynamics, except for the LVdP/dtmax, which decreased by 11% during the interventions and did not recover during the following reperfusion period of 2 hours (78% of baseline, p < 0.05). Systolic segment length shortening and EW were increased at the end of the first occlusion-reperfusion cycle, decreased gradually during the remainder of the occlusion-reperfusion periods, and did not improve during the recovery period. Energy charge and myocardial blood flow were not impaired, but oxygen consumption was decreased during the recovery period. The malondialdehyde data did not provide evidence for production of oxygen free radicals.(ABSTRACT TRUNCATED AT 250 WORDS)