Anti-Anginal Effectiveness and Tolerability of Trimetazidine Modified Release 80 Mg Once Daily in Stable Angina Patients in Real-World Practice

Percutaneous coronary revascularization versus medical therapy in chronic coronary syndromes: An updated meta-analysis of randomized controlled trials

INTRODUCTION

Coronary artery disease (CAD) is a main cause of morbidity and mortality. The effectiveness of coronary revascularization in chronic coronary syndromes (CCS) is still debated. Our recent study showed the superiority of coronary revascularization over optimal medical therapy (OMT) in reducing cardiovascular (CV) mortality and myocardial infarction (MI). The recent publication of the ORBITA-2 trial suggested superiority of percutaneous coronary revascularization (PCI) in reducing angina and improving quality of life. Therefore, we aimed to provide an updated meta-analysis evaluating the impact of PCI on both clinical outcomes and angina in CCS.

METHODS

Relevant studies were screened in PubMed/Medline until 08/01/2024. Randomized controlled trials (RCTs) comparing PCI to OMT in CCS were selected. The primary outcome was CV death. Secondary outcomes were MI, all-cause mortality, stroke, major bleeding and angina severity.

RESULTS

Nineteen RCTs involving 8616 patients were included. Median follow-up duration was 3.3 years. Revascularization significantly reduced CV death (4.2% vs. 5.5%; OR = .77; 95% CI .62-.96, p = .02). Subgroup analyses favoured revascularization in patients without chronic total occlusions (CTOs) (p = .052) and those aged <65 years (p = .02). Finally, a follow-up duration beyond 3 years showed increased benefit of coronary revascularization (p = .04). Secondary outcomes analyses showed no significant differences, except for a lower angina severity in the revascularization group according to the Seattle Angina Questionnaire (SAQ) (p = .04) and to the Canadian Cardiovascular Society (CCS) classification (p = .005).

CONCLUSIONS

PCI compared to OMT significantly reduces CV mortality and angina severity, improving quality of life in CCS patients. This benefit was larger without CTOs, in patients aged <65 years and with follow-up duration beyond 3 years.

ACAA2 is a novel molecular indicator for cancers with neuroendocrine phenotype

BACKGROUND

Neuroendocrine phenotype is commonly associated with therapy resistance and poor prognoses in small-cell neuroendocrine cancers (SCNCs), such as neuroendocrine prostate cancer (NEPC) and small-cell lung cancer (SCLC). Expression levels of current neuroendocrine markers exhibit high case-by-case variability, so multiple markers are used in combination to identify SCNCs. Here, we report that ACAA2 is elevated in SCNCs and is a potential molecular indicator for SCNCs.

METHODS

ACAA2 expressions in tumour xenografts, tissue microarrays (TMAs), and patient tissues from prostate and lung cancers were analysed via immunohistochemistry. ACAA2 mRNA levels in lung and prostate cancer (PC) patients were assessed in published datasets.

RESULTS

ACAA2 protein and mRNA levels were elevated in SCNCs relative to non-SCNCs. Medium/high ACAA2 intensity was observed in 78% of NEPC PDXs samples (N = 27) relative to 33% of adeno-CRPC (N = 86), 2% of localised PC (N = 50), and 0% of benign prostate specimens (N = 101). ACAA2 was also elevated in lung cancer patient tissues with neuroendocrine phenotype. 83% of lung carcinoid tissues (N = 12) and 90% of SCLC tissues (N = 10) exhibited medium/high intensity relative to 40% of lung adenocarcinoma (N = 15).

CONCLUSION

ACAA2 expression is elevated in aggressive SCNCs such as NEPC and SCLC, suggesting it is a potential molecular indicator for SCNCs.

Dysregulation of metabolic pathways in pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic progressive disorder of unknown origin and the most common interstitial lung disease. It progresses with the recruitment of fibroblasts and myofibroblasts that contribute to the accumulation of extracellular matrix (ECM) proteins, leading to the loss of compliance and alveolar integrity, compromising the gas exchange capacity of the lung. Moreover, while there are therapeutics available, they do not offer a cure. Thus, there is a pressing need to identify better therapeutic targets. With the advent of transcriptomics, proteomics, and metabolomics, the cellular mechanisms underlying disease progression are better understood. Metabolic homeostasis is one such factor and its dysregulation has been shown to impact the outcome of IPF. Several metabolic pathways involved in the metabolism of lipids, protein and carbohydrates have been implicated in IPF. While metabolites are crucial for the generation of energy, it is now appreciated that metabolites have several non-metabolic roles in regulating cellular processes such as proliferation, signaling, and death among several other functions. Through this review, we succinctly elucidate the role of several metabolic pathways in IPF. Moreover, we also discuss potential therapeutics which target metabolism or metabolic pathways.

Effectiveness and Tolerability of Trimetazidine 80 Mg Once Daily in Patients with Stable Angina Uncontrolled with Bisoprolol-Based Therapy: The Modus Vivendi Observational Study

Introduction

Modus Vivendi was conducted in routine clinical practice to evaluate the effect of adding trimetazidine 80 mg once daily (TMZ 80 OD) to treat patients with persistent symptoms despite treatment with background antianginal therapies including maximally tolerated bisoprolol.

Methods

This multicenter, prospective, observational, open-label, uncontrolled study recruited adult outpatients with a confirmed diagnosis of stable angina to whom physicians had decided to prescribe TMZ 80 OD. All patients were symptomatic despite treatment, including maximally tolerated doses of bisoprolol. Data on number of angina attacks, use of short-acting nitrates, and quality of life (QoL) were collected at baseline (V1) and at 1-month (V2) and 3-month (V2) follow-up visits. Two sub-analyses assessed efficacy in patients who remained on a stable bisoprolol dose throughout the study, and in patients in whom background antianginal therapy was known.

Results

A total of 1939 patients were recruited (57.2% women). The mean age was 65.6 ± 8.8 years; 73.8% had class II and 26.2% class III angina. At V1, the mean number of angina attacks per week was 6.2 ± 6.5 despite antianginal therapy including maximally tolerated bisoprolol dosage. Following the addition of TMZ 80 OD, this decreased to 3.4 ± 4.2 attacks per week at V2, and 1.6 ± 2.6 at V3 (P < 0.05 at V2 and V3), with concomitant reductions in short-acting nitrate use (P < 0.05). Significant improvements in QoL were observed throughout the study. Subgroup analyses showed that the addition of TMZ 80 OD to guideline-recommended antianginal therapy was associated with significant reductions in the mean number of weekly angina attacks and consumption of short-acting nitrates and improvements in QoL whether patients were treated with maximally tolerated bisoprolol and TMZ 80 OD alone, or maximally tolerated bisoprolol and TMZ 80 OD on top of other antianginal therapies. Treatment was well tolerated.

Conclusion

The study findings support the addition of TMZ 80 OD to bisoprolol with or without other antianginal therapies for patients with persistent angina.

Trial Registration

This study was retrospectively registered under the number ISRCTN29992579.

Trimetazidine reduces contrast-induced nephropathy in patients with renal insufficiency undergoing coronary angiography and angioplasty: A systematic review and meta-analysis (PRISMA)

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.

Effectiveness of Trimetazidine in Patients with Stable Angina Pectoris of Various Durations: Results from ODA

INTRODUCTION

Trimetazidine (TMZ) is an antianginal agent that acts directly at the myocardial cell level and which is now available in a once-daily (od) formulation.

METHODS

ODA, a 3-month, observational, multicenter study in Russia, assessed the effectiveness and tolerability of TMZ 80 mg od in patients with stable angina and persisting symptoms, in real-life settings. The present analysis explored the effects of adding TMZ to background antianginal treatment with respect to the duration of stable angina.

RESULTS

A total of 3032 patients were divided into four groups according to stable angina pectoris duration since diagnosis, ranging from less than 1 year to more than 10 years. A decrease in frequency of angina attacks was observed, including in patients with angina duration < 1 year, in whom the frequency of weekly angina attacks decreased from 3.8 ± 2.9 to 1.4 ± 1.7 at 1 month and 0.6 ± 1.0 at 3 months. Short-acting nitrate consumption and proportion of angina-free patients decreased, and self-reported physical activity and adherence to antianginal therapy improved in all patient groups, including recently diagnosed patients and starting already at month 1.

CONCLUSIONS

Addition of TMZ 80 mg od to antianginal treatment was effective in reducing the frequency of angina attacks and the use of short-acting nitrates, improving Canadian Cardiovascular Society (CCS) class, self-reported physical activity, and adherence to antianginal therapy. These beneficial effects were observed in patient groups with different durations of stable angina, suggesting an opportunity for decreasing angina burden even in recently diagnosed patients.

TRIAL REGISTRATION

ISRCTN registry Identifier, ISRCTN97780949.

[Evaluation of the antianginal effectiveness of trimetazidine in a new dosage form for a single dose, depending on the region of the Russian Federation. ODA trial results]

The goal evaluation of the effectiveness of treatment with the new TMZ OD dosage form in different regions of the Russian Federation and regional differences in the clinical characteristics of patients with coronary artery disease included in the observation, the nature of their therapy, the presence and degree of correction of modifiable risk factors in real clinical practice.

MATERIAL

Used database research ODA (Evaluation of the effectiveness and therapeutic response to Preductal OD 80 mg in everyday practical use for the treatment of stable angina), which was conducted in 56 cities of the Russian Federation. The analysis was carried out in the Central, North-West, Volga districts and regions united by the territorial principle - Southern + North Caucasian + Crimea + Sevastopol and Ural + Siberian + Far Eastern.

RESULTS

By region, there were no differences in the ratio of men and women included in the observation, the number of smoking patients (about 15%), overweight (about 80% of patients), arterial hypertension (exceeding 85%),dyslipidemia (over 90%), and atrial fibrillation (met at each 8-10 included patient). The proportion of patients older than 65 years was greater in the Central, North-West and Ural regions. Unfavorable heredity in coronary artery disease is more common in the Southern, Central and Ural regions. More than 2/3 of the patients had low physical activity, and in the South - their number reached ¾ of all included in the observation. The largest number of patients with diabetes was in the Central and North-West regions (every fourth patient), in the Ural region every fifth. The lowest frequency of statin prescribing was in the Volga region. The smallest number of those receiving RAS inhibitors was in the North-West, Ural and South regions. Beta blockers took more than 80% of patients. Only 35% of patients had a target systolic blood pressure. The smallest proportion of people with target blood pressure values was in the NorthWest and South regions. Adding TMZ OD to therapy or replacing previous therapy with trimetazidine on TMZ OD in all regions resulted in a significant (p &lt;0.001) decrease in the incidence of angina attacks by as early as 1 month of therapy and the antianginal effect increased by the third month of treatment. By the third month of treatment, the average frequency of angina attacks was the lowest in the North-Western and Ural regions (significantly lower than even in the Central region) and remained higher only in the Volga region compared to the Central, North-Western and Ural regions. During follow-up, treatment compliance increased significantly in all regions.

CONCLUSION

The fight against major risk factors remains insufficient and efforts should be made to change the situation in all regions of the Russian Federation. The inclusion of trimetazidine in therapy in the new TMZ OD dosage form allows to obtain a pronounced antianginal effect and increase adherence to therapy. Low adherence can be overcome by careful observation and closer contact between doctors and patients.

Effectiveness of Long-acting Trimetazidine in Different Clinical Situations in Patients with Stable Angina Pectoris: Findings from ODA Trial

Introduction

Trimetazidine (TMZ) has been shown to be efficacious for angina treatment. The TMZ 80-mg formulation allows one-daily (od) dosage, which could improve symptom control and adherence.

Methods

The 3-month, observational, multicenter, prospective ODA (antianginal effectiveness and tolerability of trimetazidine modified release 80 mg Once Daily in stable Angina patients in real-world practice) study assessed TMZ 80 mg od effectiveness in stable angina patients with persistent symptoms despite therapy. Two clinical situations were compared: patients who initiated treatment with TMZ 80 mg od (initiation group) and patients who were previously treated with TMZ 20 mg thrice daily (tid) or TMZ 35 mg MR twice daily (bid) and switched to TMZ 80 mg od (switch group). Number of angina attacks, short-acting nitrate (SAN) consumption, self-reported patient daily activity, Canadian Cardiovascular Society (CCS) class, adherence to antianginal therapy, overall efficacy and tolerability were assessed.

Results

A significant decrease in weekly number of angina attacks was observed for both the initiation group (n = 1841 patients) from 4.8 ± 3.5 at baseline to 0.9 ± 1.4 at 3 months (M3) (P < 0.001), and the switch group (n = 1216 patients) from 4.4 ± 1.3 at baseline to 0.9 ± 1.3 at M3 (P < 0.001). Significant reduction in SAN consumption and improvement in CCS class were observed for both groups. Adherence to antianginal therapy improved in both groups at 1 month (M1) and M3. Overall effectiveness of TMZ 80 mg od was rated by physicians as “very good” (68% initiation group, 70% switch group), “good” (31% initiation group, 29% switch group), “moderate” (1%, both groups) or “poor” (< 1%, both groups). Overall tolerability of TMZ 80 mg od was rated by physicians as “very good” (75%), “good” (25%) or “moderate” (< 1%) in both groups.

Conclusions

TMZ 80 mg od, in association with other antianginal therapy, effectively reduced angina attacks and SAN consumption and improved physical activity and adherence to antianginal therapy both in patients initiating TMZ treatment and those switching from a bid or tid formulation.

Trial Registration

ISRCTN registry Identifier, ISRCTN97780949.

Funding

Servier.

Plain Language Summary

Plain language summary available for this article.

Electronic supplementary material

The online version of this article (10.1007/s40119-019-0128-3) contains supplementary material, which is available to authorized users.