Therapeutic value of a cardioprotective agent in patients with severe ischaemic cardiomyopathy

Cardioprotective Effects of Dapagliflozin and Trimetazidine on Doxorubicin-Induced Cardiotoxicity in Streptozotocin-Induced Type 1 Diabetic Rats via Endoplasmic Reticulum Stress

Background/Objectives: Diabetic cardiomyopathy is a distinct myocardial dysfunction characterized by structural and functional changes in the heart that occur in diabetic patients independently of coronary artery disease or hypertension. It is closely associated with oxidative stress, inflammation, mitochondrial dysfunction, and endoplasmic reticulum (ER) stress, and contributes to progressive cardiac damage. This study aimed to evaluate the cardioprotective effects of dapagliflozin (DAPA) and trimetazidine (TMZ) in a rat model of doxorubicin-induced cardiomyopathy with streptozotocin-induced diabetes, focusing on their potential mechanisms related to ER stress. Methods: A total of 48 Sprague Dawley rats aged 6-8 weeks were randomly distributed equally into six cages. The diabetes model was induced by intraperitoneal administration of streptozotocin (STZ) and rats with blood glucose levels above 250 mg/dL were considered diabetic. For those rats with diabetes, cardiotoxicity was induced by intraperitoneal injection of 5 mg/kg/week doxorubicin (DOXO) for 4 weeks. After a cumulative dose of 20 mg/kg doxorubicin, a week break was given, followed by the administration of TMZ (10 mg/kg) and/or DAPA (10 mg/kg) to the treatment groups. Results: STZ administration caused diabetes and significant degeneration in cardiomyocytes. With the addition of DOXO (STZ + DOXO), cardiomyocyte degeneration became more severe. When the study groups were histopathologically evaluated based on parameters of degenerative cardiomyocytes, vascular congestion, and edema, it was shown that both TMZ and DAPA, whether applied alone or in combination, reduced damage in heart tissue. Both TMZ and DAPA reduced cardiomyocyte damage, and their combination provided the lowest level of damage through the reduced ER stress pathway by reducing GRP 78 and CHOP positivity. Conclusions: TMZ and DAPA reduce ER stress and have protective effects against diabetic-induced cardiotoxicity. Combination therapy or TMZ was found to be more effective than DAPA in alleviating ER stress. Combination therapy appears to carry potential effects for reducing cardiac cell damage in individuals with diabetes.

Metabolic intervention with trimetazidine improves intracardiac hemodynamics and reduces re-hospitalizations in patients with advanced heart failure

OBJECTIVES

We tested whether management with metabolic cytoprotective and antiischemic agent trimetazidine may reduce readmissions in advanced heart failure (HF) patients through the possible improvement of left ventricular ejection fraction (LV EF) and filling pressure.

METHODS

This was a single-center prospective open-label study. The study population included initially 40 patients with advanced HF and EF <30%, NYHA III-IV functional class, significant restriction of physical activity and at least 1 hospitalization during the last 12 months. After discharge patients were assigned to additional treatment with trimetazidine 80 mg/daily dose (20 patients) or standard guideline-based pharmacological therapy (20 patients). After enrollment patients underwent a total of four outpatient clinical and echocardiographic examinations (baseline before discharge, 2 weeks, 1, 3 and 6 months after the discharge). The echocardiographic assessment of EF and LV filling pressure by Tissue Doppler were performed blindly.

RESULTS

At 6 months, trimetazidine-treated patients had an improvement of LV EF (from 23.7% to 25%) as compared to controls (from 22.5% to 22.6%). Tissue Doppler study showed a decrease of LV filling pressure in trimetazidine treated group from 15.1 at baseline to 13.7 after 6 months of treatment. In the control group, LV filling pressure remained unchanged (from 16.78 to 16.7) (P<0.001). The rate of hospitalizations for cardiovascular causes was reduced at 6 months (83.3% vs 70.0%).

CONCLUSIONS

Treatment with trimetazidine 80 mg/daily in addition to standard guideline-based therapy for 6-months decreased hospitalization, improved systolic function and LV filling pressure in advanced HF patients.

Human cardiac metabolism

The heart is the most metabolically active organ in the human body, and cardiac metabolism has been studied for decades. However, the bulk of studies have focused on animal models. The objective of this review is to summarize specifically what is known about cardiac metabolism in humans. Techniques available to study human cardiac metabolism are first discussed, followed by a review of human cardiac metabolism in health and in heart failure. Mechanistic insights, where available, are reviewed, and the evidence for the contribution of metabolic insufficiency to heart failure, as well as past and current attempts at metabolism-based therapies, is also discussed.

Effects of trimetazidine on heart failure with reduced ejection fraction and associated clinical outcomes: a systematic review and meta-analysis

BACKGROUND

Despite maximal treatment, heart failure (HF) remains a major clinical challenge. Besides neurohormonal overactivation, myocardial energy homoeostasis is also impaired in HF. Trimetazidine has the potential to restore myocardial energy status by inhibiting fatty acid oxidation, concomitantly enhancing glucose oxidation. Trimetazidine is an interesting adjunct treatment, for it is safe, easy to use and comes at a low cost.

OBJECTIVE

We conducted a systematic review to evaluate all available clinical evidence on trimetazidine in HF. We searched Medline/PubMed, Embase, Cochrane CENTRAL and ClinicalTrials.gov to identify relevant studies.

METHODS

Out of 213 records, we included 28 studies in the meta-analysis (containing 2552 unique patients), which almost exclusively randomised patients with HF with reduced ejection fraction (HFrEF). The studies were relatively small (median study size: N=58) and of short duration (mean follow-up: 6 months), with the majority (68%) being open label.

RESULTS

Trimetazidine in HFrEF was found to significantly reduce cardiovascular mortality (OR 0.33, 95% CI 0.21 to 0.53) and HF hospitalisations (OR 0.42, 95% CI 0.29 to 0.60). In addition, trimetazidine improved (New York Heart Association) functional class (mean difference: -0.44 (95% CI -0.49 to -0.39), 6 min walk distance (mean difference: +109 m (95% CI 105 to 114 m) and quality of life (standardised mean difference: +0.52 (95% CI 0.32 to 0.71). A similar pattern of effects was observed for both ischaemic and non-ischaemic cardiomyopathy.

CONCLUSIONS

Current evidence supports the potential role of trimetazidine in HFrEF, but this is based on multiple smaller trials of varying quality in study design. We recommend a large pragmatic randomised clinical trial to establish the definitive role of trimetazidine in the management of HFrEF.

AMPK: a therapeutic target of heart failure-not only metabolism regulation

Heart failure (HF) is a serious disease with high mortality. The incidence of this disease has continued to increase over the past decade. All cardiovascular diseases causing dysfunction of various physiological processes can result in HF. AMP-activated protein kinase (AMPK), an energy sensor, has pleiotropic cardioprotective effects and plays a critical role in the progression of HF. In this review, we highlight that AMPK can not only improve the energy supply in the failing heart by promoting ATP production, but can also regulate several important physiological processes to restore heart function. In addition, we discuss some aspects of some potential clinical drugs which have effects on AMPK activation and may have value in treating HF. More studies, especially clinical trials, should be done to evaluate manipulation of AMPK activation as a potential means of treating HF.

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.

Metabolic Modulation of Cardiac Metabolism in Heart Failure

Heart failure (HF) is associated with metabolic changes that cause a progressive impairment of cardiac and skeletal muscle high-energy phosphate production. As a consequence of the impaired cardiac metabolism, other processes are activated in the failing heart that further exacerbate the progression of HF. The reduced production of high-energy phosphates has important implications for both systole and diastole in HF with both preserved and reduced left ventricular function. The aim of this review is to summarise the state-of-the-art on metabolic therapy in HF with a particular focus on trimetazidine. Metabolic agents optimise cardiac substrate metabolism without exerting negative haemodynamic effects. In particular, as studies with metabolic agents modulating cardiac metabolism have consistently demonstrated, this approach is effective in improving symptoms, functional capacity and prognosis in people with HF when added to optimal medical therapy. Therefore, the modulation of cardiac metabolism is an important therapeutic approach to the treatment of HF, especially in patients where it is of ischaemic or metabolic origin. Although further studies are needed, metabolic agents might be a new, effective strategy for the treatment of HF.

Modulation of myocardial energetics: An important category of agents in the multimodal treatment of coronary artery disease and heart failure

The combined and relative contribution of glucose and fatty acid oxidation generates myocardial energy, which regulates the cardiac function and efficiency. Any dysregulation in this metabolic homeostasis can adversely affect the function of heart and contribute to cardiac conditions such as angina and heart failure. Metabolic agents ameliorate this internal metabolic anomaly, by shifting the energy production pathway from free fatty acids to glucose, resulting in a better performance of the heart. Metabolic therapy is relatively a new modality, which functions through optimization of cardiac substrate metabolism. Among the metabolic therapies, trimetazidine and ranolazine are the agents presently available in India. In the present review, we would like to present the metabolic perspective of pathophysiology of coronary artery disease and heart failure, and metabolic therapy by using trimetazidine and ranolazine.

WITHDRAWN: Trimetazidine for stable angina

BACKGROUND

Patients with stable angina not controlled by monotherapy with nitrates, beta blockers, or calcium channel blockers are often treated with combinations of these drugs. There may be adverse effects from, or contraindications to, the use of combinations. In low risk groups, medical treatment appears to be as good an option as percutaneous transluminal coronary angioplasty in terms of averting myocardial infarction, death, or subsequent revascularization. Revascularization procedures are too costly or inaccessible for many patients in developing countries therefore effective and safe medical treatment is needed. Trimetazidine is a less well known anti-anginal drug that controls myocardial ischaemia through intracellular metabolic changes. Trimetazidine has been reported, in some studies, to be better tolerated than combined anti-anginal therapy; however it is not considered in published guidelines.

OBJECTIVES

To determine the efficacy and tolerability of trimetazidine in patients with stable angina.

SEARCH METHODS

We searched The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, LILACS and SCISEARCH, without language restriction, from inception to October 2003. Experts in the field were contacted to locate unpublished studies.

SELECTION CRITERIA

Randomised studies comparing trimetazidine with placebo, or other anti-angina drug in adults with stable angina.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied the inclusion criteria, assessed trial quality and extracted data.

MAIN RESULTS

Twenty-three studies (1378 patients) met the inclusion criteria. There was a paucity of information about mortality, cardiovascular events and quality of life. Trimetazidine, compared with placebo, reduced the number of weekly angina attacks ( mean difference -1.44, 95% CI -2.10 to -0.79; P < 0.0001), reduced weekly nitroglycerin tablet consumption (95% CI -1.47 to -2.20, -0.73; P < 0.0001) and improved exercise time to 1 mm segment depression (P = 0.0002). Four small trials (263 patients) compared trimetazidine against other anti-anginal agents. One favoured trimetazidine over nitrates. Three tended to favour alternative regimens but with confidence intervals consistent with both major increases and decreases in frequency of angina episodes. In this subgroup, adverse events were considered in 5 trials (448 patients) and totals of 2 versus 12 drop outs due to adverse events were observed in the trimetazidine and alternative regimens respectively, but this was mostly driven by a single trial.

AUTHORS' CONCLUSIONS

Trimetazidine is effective in the treatment of stable angina compared with placebo, alone or combined with conventional anti-anginal agents. Trimetazidine may result in fewer dropouts due to adverse events. Large, long term trials comparing trimetazidine with other anti-anginal drugs assessing clinically relevant important outcomes are required to establish its role in clinical management.

Metabolic manipulation in dilated cardiomyopathy: Assessing the role of trimetazidine

OBJECTIVES

To study the role of metabolic modulator (trimetazidine: TMZ) in dilated cardiomyopathy (DCM). Optimizing altered substrate metabolism in heart failure (HF) with metabolic modulators allows more efficacious energy production from glucose than from free fatty acids.

METHODS

100 patients of DCM (47.7 years, NYHA class 2.17, LVEF 27.3%) were randomized to TMZ (20mg tid, n=50) vs conventional therapy (n=50). Functional status, BNP and various echocardiographic parameters were assessed at 3-6 months.

RESULTS

At 3 months, TMZ group had significantly improved NYHA class (2.25 vs 1.85), 6min walk test (349.7 vs 402m), LVD-36 score (25.5 vs 21) and BNP (744.7 vs 248.3pg/ml), all p 0.001. Significant improvement was also seen in LV end-systolic (LVESV, 87.1±27.5 vs 78.5±24.9ml/m2, p 0.001), LV end-diastolic volumes (LVEDV, 117.6±29.3 vs 110.9±27.4ml/m2, p 0.001), LVEF (27 vs 30.9%, p 0.001) and LV wall stress (90.2±18.9 vs 71.1±13.2dyn/cm2, p 0.0001). The % change in LVESV, LVEDV, LVEF and LV wall stress was -9.5%, -5.4%, +8.4% and -21.8%. Other echo parameters also improved after 3 months of TMZ (E/A ratio 1.9 vs 1.2, p=0.001, E/A VTI 2.7 vs 1.6, p=0.001, myocardial performance index, MPI 0.8 vs 0.7, p=0.0001), Tissue Doppler parameters (E/E' septal (19.7 vs 12.5, p=0.001) and E/E' lateral (13.3 vs 9.4, p=0.0001)). Patients in control group had no change in NYHA class, LVD-36 scores, LV volumes or LVEF at 3 months although BNP and LV wall stress reduced to a slight extent. Patients on TMZ had further improvement in NYHA class, walk test, BNP levels and echocardiographic parameters at 6 months.

CONCLUSIONS

Metabolic modulators (TMZ) may help in improving LV function in DCM. In this study, benefit was noted by 3 months with further improvement at 6 months.

Effects of sustained-release trimetazidine on chronically dysfunctional myocardium of ischemic dilated cardiomyopathy - Six months follow-up result

Background

Ischemic cardiomyopathy is a growing burden in third world countries. So far, benefits of trimetazidine in this group of patients have been suggested by clinical trials mainly conducted in Europe. We evaluated the effect of trimetazidine on ischemic dilated cardiomyopathy in our population.

Methods and results

98 patients (aged 58.5 ± 9.2 years), admitted with decompensated heart failure with previous history of MI and/or documentation of significant CAD with previous CAG, were chosen for the study. Patients were randomized into two groups – one provided with trimetazidine 35 mg sustained released tablet, twice daily and the other with a placebo, along with other conventional medications. Patients were included if they had dilated LV (LVIDd > 57 mm) and left ventricular ejection fraction (LVEF) ≤40%. After 6 months, significantly higher number of patients in trimetazidine group were in NYHA class I (22% vs. 8%, p = 0.03) and class II (56% vs. 34%, p = 0.01); higher number of patients in placebo group were in NYHA class III class IV. Anginal episodes and use of sublingual nitrate per week were significantly lower in the trimetazidine group. Left ventricular diastolic dimension (59.7 ± 5.2 vs. 65.1 ± 6.1, p = 0.001) was significantly different in the two groups as was the increase of LVEF (11% vs. 5.6%, p = 0.001). Hospitalization for worsening heart failure was significantly lower in trimetazidine group (13 vs. 22, p = 0.047).

Conclusion

Trimetazidine seems to be beneficial in patients with ischemic dilated cardiomyopathy in South Asian population and larger scale study with extended follow-up is needed.

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.

Deranged Cardiac Metabolism and the Pathogenesis of Heart Failure

Activation of the neuro-hormonal system is a pathophysiological consequence of heart failure. Neuro-hormonal activation promotes metabolic changes, such as insulin resistance, and determines an increased use of non-carbohydrate substrates for energy production. Fasting blood ketone bodies as well as fat oxidation are increased in patients with heart failure, yielding a state of metabolic inefficiency. The net result is additional depletion of myocardial adenosine triphosphate, phosphocreatine and creatine kinase levels with further decreased efficiency of mechanical work. In this context, manipulation of cardiac energy metabolism by modification of substrate use by the failing heart has produced positive clinical results. The results of current research support the concept that shifting the energy substrate preference away from fatty acid metabolism and towards glucose metabolism could be an effective adjunctive treatment in patients with heart failure. The additional use of drugs able to partially inhibit fatty acids oxidation in patients with heart failure may therefore yield a significant protective effect for clinical symptoms and cardiac function improvement, and simultaneously ameliorate left ventricular remodelling. Certainly, to clarify the exact therapeutic role of metabolic therapy in heart failure, a large multicentre, randomised controlled trial should be performed.

Metabolic Therapy in Heart Failure

Metabolic impairments play an important role in the development and progression of heart failure. The use of metabolic modulators, the number of which is steadily increasing, may be particularly effective in the treatment of heart failure. Recent evidence suggests that modulating cardiac energy metabolism by reducing fatty acid oxidation and/or increasing glucose oxidation represents a promising approach to the treatment of patients with heart failure. This review focuses on the role of metabolic modulators, in particular trimetazidine, as a potential additional medication to conventional medical therapy in heart failure.

Defining the role of trimetazidine in the treatment of cardiovascular disorders: some insights on its role in heart failure and peripheral artery disease

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.

Is treatment with trimetazidine beneficial in patients with chronic heart failure?

BACKGROUND

Whether additional benefit can be achieved with the use of trimetazidine (TMZ) in patients with chronic heart failure (CHF) remains controversial. We therefore performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the effects of TMZ treatment in CHF patients.

METHODS

We searched PubMed, EMBASE, and Cochrane databases through October 2013 and included 19 RCTs involving 994 CHF patients who underwent TMZ or placebo treatment. Risk ratio (RR) and weighted mean differences (WMD) were calculated using fixed or random effects models.

RESULTS

TMZ therapy was associated with considerable improvement in left ventricular ejection fraction (WMD: 7.29%, 95% CI: 6.49 to 8.09, p<0.01) and New York Heart Association classification (WMD: -0.55, 95% CI: -0.81 to -0.28, p<0.01). Moreover, treatment with TMZ also resulted in significant decrease in left ventricular end-systolic volume (WMD: -17.09 ml, 95% CI: -20.15 to -14.04, p<0.01), left ventricular end-diastolic volume (WMD: -11.24 ml, 95% CI: -14.06 to -8.42, p<0.01), hospitalization for cardiac causes (RR: 0.43, 95% CI: 0.21 to 0.91, p = 0.03), B-type natriuretic peptide (BNP; WMD: -157.08 pg/ml, 95% CI: -176.55 to -137.62, p<0.01) and C-reactive protein (CRP; WMD: -1.86 mg/l, 95% CI: -2.81 to -0.90, p<0.01). However, there were no significant differences in exercise duration and all-cause mortality between patients treated with TMZ and placebo.

CONCLUSIONS

TMZ treatment in CHF patients may improve clinical symptoms and cardiac function, reduce hospitalization for cardiac causes, and decrease serum levels of BNP and CRP.

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.

Effects of trimetazidine in nonischemic heart failure: a randomized study

OBJECTIVES

Heart failure (HF) is associated with changes in myocardial metabolism that lead to impairment of contractile function. Trimetazidine (TMZ) modulates cardiac energetic efficiency and improves outcomes in ischemic heart disease. We evaluated the effects of TMZ on left ventricular ejection fraction (LVEF), cardiac metabolism, exercise capacity, O2 uptake, and quality of life in patients with nonischemic HF.

METHODS AND RESULTS

Sixty patients with stable nonischemic HF under optimal medical therapy were included in this randomized double-blind study. Patients were randomized to TMZ (35 mg orally twice a day) or placebo for 6 months. LVEF, 6-minute walk test (6MWT), maximum O2 uptake in cardiopulmonary exercise test, different markers of metabolism, oxidative stress, and endothelial function, and quality of life were assessed at baseline and after TMZ treatment. Left ventricular peak glucose uptake was evaluated with the use of the maximum standardized uptake value (SUV) by 18-fluorodeoxyglucose positron emission tomography ((18)FDG-PET). Etiology was idiopathic in 85% and hypertensive in 15%. Both groups were similar in age, functional class, LVEF, and levels of N-terminal pro-B-type natriuretic peptide at baseline. After 6 months of TMZ treatment, no changes were observed in LVEF (31 ± 10% vs 34 ± 8%; P = .8), 6MWT (443 ± 25 m vs 506 ± 79 m; P = .03), maximum O2 uptake (19.1 ± 5.0 mL kg(-1) min(-1) vs 23.0 ± 7.2 mL kg(-1) min(-1); P = .11), functional class (percentages of patients in functional classes I/II/III/IV 10/3753/0 vs 7/40/50/3; P = .14), or quality of life (32 ± 26 points vs 24 ± 18 points; P = .25) in TMZ versus placebo, respectively. In the subgroup of patients evaluated with (18)FDG-PET, no significant differences were observed in SUV between both groups (7.0 ± 3.6 vs 8.2 ± 3.4 respectively; P = .47).

CONCLUSIONS

In patients with nonischemic HF, the addition of TMZ to optimal medical treatment does not result in significant changes of LVEF, exercise capacity, O2 uptake, or quality of life.

Effects of trimetazidine in patients with acute myocardial infarction: data from the Korean Acute Myocardial Infarction Registry

BACKGROUND

Excess myocardial fatty acid oxidation can cause a range of deleterious myocardial effects. Trimetazidine (TMZ) is a clinically effective antianginal agent that selectively inhibits long-chain 3-ketoacyl CoA thiolase, reducing fatty acid oxidation and stimulating glucose oxidation. The role of TMZ in acute myocardial infarction (AMI), however, remains unclear. Our retrospective analysis explores the effect on clinical outcomes of adding TMZ to standard treatment in patients with AMI.

METHODS

All 13,733 AMI patients registered in the Korean Acute Myocardial Infarction Registry from 2005 to 2008 were retrospectively enrolled. Patients were divided into two groups: those treated with TMZ during their in-hospital management period and those who were not. Primary endpoints were all-cause death combined in-hospital and 12-month death and major adverse cardiac events (MACE), which included all-cause death, recurrent myocardial infarction (MI), repeated percutaneous coronary intervention (PCI) for target lesion revascularization (TLR), and coronary artery bypass graft. Propensity-matched patients were analyzed using an adjusted Cox proportional hazards model.

RESULTS

Baseline clinical and angiographic characteristics in the TMZ and no-TMZ groups were generally similar, with the exceptions of pre-PCI thrombolysis in myocardial infarction flow grade, stent type, and stent length. Over 12 months, the relative risk of all-cause death fell by 59 % (event rate 2.3 vs. 6.4 %; hazard ratio 0.41, 95 % CI 0.18-0.97, P = 0.042) and the relative risk of MACE fell by 76 % (event rate 2.3 vs. 9.5 %; hazard ratio 0.24, 95 % CI 0.10-0.56, P = 0.001) in the TMZ group compared with those in the no-TMZ group.

CONCLUSIONS

Trimetazidine appeared to improve clinical outcomes in AMI patients by significantly reducing all-cause mortality and MACE over 12 months.

Additional use of trimetazidine in patients with chronic heart failure: a meta-analysis

OBJECTIVES

The aim of this meta-analysis was to evaluate the effects of additional trimetazidine (TMZ) treatment on patients with chronic heart failure (CHF).

BACKGROUND

Conflicting results currently exist on the clinical use of TMZ in CHF patients.

METHODS

PubMed, MEDLINE, EMBASE, and EBM Reviews databases were searched through November 2010 for randomized controlled trials (RCTs) assessing TMZ treatment in CHF patients. Data concerning the study design, patient characteristics, and outcomes were extracted. Risk ratio (RR) and weighted mean differences (WMD) were calculated using fixed or random effects models.

RESULTS

Sixteen RCTs involving 884 CHF patients were included. Hospitalization for cardiac causes (RR: 0.43, p = 0.03), but not all-cause mortality (RR: 0.47, p = 0.27), was reduced by TMZ treatment. Moreover, TMZ therapy was associated not only with the increase of left ventricular ejection fraction (WMD: 6.46%, p < 0.0001) and total exercise time (WMD: 63.75 seconds, p < 0.0001), but also with the decrease of New York Heart Association functional class (WMD: -0.57, p = 0.0003), left ventricular end-systolic diameter (WMD: -6.67 mm, p < 0.0001), left ventricular end-diastolic diameter (WMD: -6.05 mm, p < 0.0001), and B-type natriuretic peptide (WMD: -203.40 pg/ml, p = 0.0002).

CONCLUSIONS

Additional use of TMZ in CHF patients may decrease hospitalization for cardiac causes, improve clinical symptoms and cardiac function, and simultaneously ameliorate left ventricular remodeling.

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.

Improved left and right ventricular functions with trimetazidine in patients with heart failure: a tissue Doppler study

Downregulation of glucose and fatty acid oxidation occurs in heart failure (HF). Trimetazidine reduces fatty acid oxidation and increases glucose oxidation. In this single-blind study, trimetazidine, 20 mg three times per day (n = 51) or placebo (n = 36) was added to treatment of 87 HF patients receiving optimal HF therapy. Etiology of heart failure was coronary artery disease in 35 patients (68.6%) in the trimetazidine group and 22 (62.9%) in the placebo group. Fourteen (27.5%) patients in the trimetazidine group and 11 (31.4%) patients in the placebo group had diabetes. Peak systolic velocity (Vs), and the peak early diastolic (Vd) and late diastolic (Va) velocities of various segments left and right ventricles (RV) were obtained with tissue Doppler imaging (TDI) and averaged. Patients were re-evaluated three months later. Significant increases in mean left ventricular ejection fraction (LVEF) (33.3% +/- 5.6% to 42.4% +/- 6.3%, P < 0.001 and 30.6% +/- 8.2% to 33.2% +/- 6.6%, P = 0.021) and LV and RV myocardial velocities and mitral and tricuspid annular TDI velocities were observed in both groups. However, compared to placebo, increments in LVEF (9.1% +/- 4.2% vs. 2.5% +/- 1.4%, P < 0.001) and myocardial velocities were significantly higher with trimetazidine (P < 0.001 for LV Vs, Vd, Va; P = 0.035 for RV Vd; and P < 0.001 for RV Va and Vs). Increase in LVEF with trimetazidine was significantly correlated with presence of diabetes (r = 0.524, P < 0.001). With trimetazidine LVEF increased significantly more in diabetic patients compared to nondiabetics (P < 0.001). Also, patients having both diabetes and ischemic HF tended to have greater improvement in LVEF compared to ischemic HF patients without diabetes (P = 0.063). Addition of trimetazidine to current treatment of HF, especially for those who are diabetic, may improve LV and RV functions.

The effects of trimetazidine on p-wave duration and dispersion in heart failure patients

BACKGROUND

P-wave duration and dispersion (PWD) have been shown to be noninvasive predictors for development of atrial fibrillation. Thus, it may be possible to attenuate atrial fibrillation risk through normalization of P-wave duration and dispersion. Trimetazidine, a metabolic modulator, has been reported to improve cardiac function in heart failure (HF) patients.

METHODS

Thirty-six HF patients being treated with angiotensin inhibitors, carvedilol, spironolactone, and furosemide were prescribed trimetazidine, 20 mg three times a day. Electrocardiographic and echocardiographic examinations were obtained before and 6 months after addition of trimetazidine in HF patients and 36 healthy control group patients having normal echocardiographic examination.

RESULTS

Maximum P-wave duration (Pmax) (106.7 +/- 15.8 vs. 91.7 +/- 12.7 ms) and PWD (57.2 +/- 15.4 vs. 37.9 +/- 16.7 ms) were significantly longer in HF patients compared to the control group. There were significant correlations of Pmax and PWD with left atrial diameter (r = 0.508, P = < 0.001 and r = 0.315, P = 0.029), left ventricular ejection fraction (LVEF) (r = 0.401, p = 0.005 and r = 0.396, P = 0.005), deceleration time (r = 0.296, P = 0.032 and r = 0.312, P = 0.035), and isovolumetric relaxation time (r = 0.265, P = 0.038 and r = 0.322, P = 0.015). There were significant improvements in LVEF (32.7 +/- 6.5% to 37.2 +/- 5.5%, P = 0.036), left atrial diameter (41.5 +/- 6.7 to 40.3 +/- 6.1 mm, P < 0.001), and Pmax (106.7 +/- 15.8 to 102.2 +/- 11.5 ms, P = 0.006) and PWD (57.2 +/- 15.4 to 48.9 +/- 10.1 ms, P < 0.001) during follow-up.

CONCLUSIONS

Trimetazidine added to optimal medical therapy in HF may improve Pmax and PWD in association with improved left ventricular function. Longer-term and larger studies are necessary to evaluate whether these findings may have clinical implications on prevention of atrial fibrillation.

Trimetazidine potentiates the effects of exercise training in patients with ischemic cardiomyopathy referred for cardiac rehabilitation

BACKGROUND

Patients referred for cardiac rehabilitation may take advantage from combining trimetazidine (TMZ) with exercise training (ET), as both treatments produce similar effects in the cardiovascular system. It is, however, unknown whether the combination of TMZ with ET may determine greater improvements in functional capacity and endothelial function than ET alone.

DESIGN

A randomized longitudinal controlled study.

METHODS

We studied 116 patients (97 men and 19 women, mean age 58+/-9 years) with ischemic heart disease and left ventricular dysfunction who were referred for cardiac rehabilitation. Coronary risk factors were present in 82 patients (diabetes in 28 patients). Patients were randomized into three matched groups. A group (TMZ+training, TT, n=30) received TMZ at doses of 20 mg three times daily orally for 8 weeks in addition to standard medications and underwent a supervised program of ET at 60% of oxygen uptake at peak, three times a week for 8 weeks. A group (exercise, E, n=30) completed the ET program without receiving TMZ. A control group (C, n=26) was neither exercised nor received TMZ. A fourth group (TMZ, n=30) receiving TMZ 20 mg three times daily for 8 weeks was also studied. On study entry and at 8 weeks all patients underwent echocardiography, cardiopulmonary exercise testing, and vasomotor reactivity of the brachial artery.

RESULTS

Oxygen uptake at peak was significantly increased in the TT (25%), TMZ (15.1%), and E group (15.3%) (P<0.001 TT vs. C; P<0.05 vs. TMZ and E). Left ventricular ejection fraction was also improved in TT (18.4%), TMZ (15.7%), and E (12.9%) (P<0.001 TT vs. C; P<0.05 vs. TMZ and E), as a result of reduction in end-systolic volume. The endothelium-dependent dilation was similarly improved (P<0.001 TMZ vs. C; P<0.05 vs. TMZ and E). The most significant improvements were observed in the subgroup TT with multiple risk factors.

CONCLUSION

The addition of TMZ to ET determined greater improvements in functional capacity, left ventricular ejection fraction, and endothelium-dependent dilation than TMZ or ET given alone. No differences between improvements after TMZ and E as compared with controls were observed.

Effects of trimetazidine on myocardial perfusion and left ventricular systolic function in type 2 diabetic patients with ischemic cardiomyopathy

AIMS

To determine whether short-term treatment with trimetazidine (TMZ), an antiischemic agent that directly inhibits fatty acid oxidation and results in stimulation of glucose oxidation, may improve myocardial perfusion and left ventricular systolic function in diabetic patients with ischemic cardiomyopathy.

METHODS AND RESULTS

We studied 34 clinically stable patients with type 2 diabetes mellitus (DM) and documented multivessel coronary artery disease (29 men and 5 women, mean age 54 +/- 9 years) with depressed systolic function (left ventricular ejection fraction 38 +/- 6%). Patients were randomized into two groups. One group received TMZ (20 mg tid) for 3 months (n = 19), while another group received a placebo during the same period (n = 15). On study entry and at 3 months, all patients underwent a gated Single Photon Emission Computed Tomography (SPECT) myocardial scintigraphy with a 2-day stress(Bruce)-rest protocol (500 MBq tetrofosmin). At 3 months, TMZ-treated patients had a significant improvement in systolic wall thickening (P < 0.05) and ejection fraction (P = 0.007) as compared with control patients. These effects were more marked in patients with more severe reversible perfusion defects on initial evaluation and were not associated with changes in myocardial defects (P = 0.38). Total exercise time was also improved in TMZ-treated patients (20.5%, P < 0.05 vs. controls).

CONCLUSIONS

In diabetic cardiomyopathy, short-term TMZ improved left ventricular systolic function and functional capacity despite no change in myocardial perfusion. These benefits were more evident in patients with more severe perfusion defects on initial evaluation, suggesting that chronic myocardial ischemia is a requirement for the effects of TMZ on left ventricular systolic performance.

Trimetazidine revisited: a comprehensive review of the pharmacological effects and analytical techniques for the determination of trimetazidine

Trimetazidine (TMZ) is an effective and well-tolerated antianginal drug that possesses protective properties against ischemia-induced heart injury. Growing interest in metabolic modulation in recent years urged an up-to-date review of the literature on TMZ. This review consists of two major sections: (1) comprehensive and critical information about the pharmacological effects, mechanism of action, pharmacokinetics, side effects, and current usage of TMZ, and (2) developments in analytical techniques for the determination of the drug in raw material, pharmaceutical dosage forms, and biological samples.

Myocardial fatty acid metabolism and cardiac performance in heart failure

It is well established that cardiac metabolism is abnormal in heart failure (HF). Experimental studies suggest that in severe HF, cardiac metabolism reverts to a more fetal-like substrate use characterized by enhanced glucose and downregulated free fatty acid (FFA) metabolism. Correspondingly, in humans, when FFA levels are similar, myocardial glucose metabolism is increased, and FFA metabolism is decreased. However, depression of left ventricular function and insulin resistance induces a shift back to greater FFA uptake and oxidation by increasing circulating FFA availability. Myocardial insulin resistance may further impair myocardial glucose uptake and lead to an energy depletion state. Experimental and preliminary clinical studies suggest that metabolic modulators enhancing myocardial glucose oxidation may improve cardiac function in patients with chronic HF. However, it has been found that acute FFA deprivation is harmful to the cardiac performance. Optimizing myocardial energy metabolism may serve as an additional approach for managing HF, but further studies are warranted.

Beneficial effects of trimetazidine treatment on exercise tolerance and B-type natriuretic peptide and troponin T plasma levels in patients with stable ischemic cardiomyopathy

BACKGROUND

In patients with ischemic cardiomyopathy, mortality rate and quality of life are unsatisfactory. We investigated the effects of the metabolic agent trimetazidine (TMZ) on exercise tolerance and prognostic markers B-type natriuretic peptide (BNP) and cardiac troponin T (cTnT) plasma levels.

METHODS

Fifty patients with ischemic cardiomyopathy were randomized either to receive TMZ (20 mg, TID) in addition to their conventional treatment (TMZ group, n = 25) or to continue their usual drug therapy (control group, n = 25) for 6 months. Patients were evaluated at baseline, at 1 month, and at 6 months (echocardiography and 6-minute walking test). At enrollment and at the end of follow-up, blood testing was performed for determination of BNP and cTnT plasma levels.

RESULTS

After 6 months, no significant New York Heart Association class changes occurred in all patients (P = NS). In the TMZ group, a significant increase of exercise tolerance (P < .01) was detected, whereas left ventricular ejection fraction was unchanged (28% +/- 4%, 29% +/- 5%, and 32% +/- 5% at baseline, at 1 month, and at 6 months, respectively; P = NS). In the TMZ group, BNP was significantly reduced (6 months, 135 +/- 22 vs 252 +/- 44 pg/mL; P < .001), whereas it was significantly increased in controls (6 months, 288 +/- 46 vs 239 +/- 59 pg/mL; P < .02); cTnT significantly (P < .001) reduced during TMZ treatment, whereas it was unchanged in the control group.

CONCLUSIONS

Six-month TMZ treatment improves exercise tolerance and reduces plasma levels of BNP and cTnT in patients with compensated ischemic cardiomyopathy.

Metabolic Mechanisms in Heart Failure

Although neurohumoral antagonism has successfully reduced heart failure morbidity and mortality, the residual disability and death rate remains unacceptably high. Though abnormalities of myocardial metabolism are associated with heart failure, recent data suggest that heart failure may itself promote metabolic changes such as insulin resistance, in part through neurohumoral activation. A detrimental self-perpetuating cycle (heart failure --> altered metabolism --> heart failure) that promotes the progression of heart failure may thus be postulated. Accordingly, we review the cellular mechanisms and pathophysiology of altered metabolism and insulin resistance in heart failure. It is hypothesized that the ensuing detrimental myocardial energetic perturbations result from neurohumoral activation, increased adverse free fatty acid metabolism, decreased protective glucose metabolism, and in some cases insulin resistance. The result is depletion of myocardial ATP, phosphocreatine, and creatine kinase with decreased efficiency of mechanical work. On the basis of the mechanisms outlined, appropriate therapies to mitigate aberrant metabolism include intense neurohumoral antagonism, limitation of diuretics, correction of hypokalemia, exercise, and diet. We also discuss more novel mechanistic-based therapies to ameliorate metabolism and insulin resistance in heart failure. For example, metabolic modulators may optimize myocardial substrate utilization to improve cardiac function and exercise performance beyond standard care. The ultimate success of metabolic-based therapy will be manifest by its capacity further to lessen the residual mortality in heart failure.

Inhibition of free fatty acids metabolism as a therapeutic target in patients with heart failure

Recent studies have evidenced that alterations of cardiac metabolism can be present in several cardiac syndromes. In heart failure, wasting of subcutaneous fat and skeletal muscle is relatively common and suggests an increased utilisation of non-carbohydrate substrates for energy production. In fact, fasting blood ketone bodies as well as fat oxidation during exercise have been shown to be increased in patients with heart failure. This metabolic shift determines a reduction of myocardial oxygen consumption efficiency. A direct approach to manipulate cardiac energy metabolism consists in modifying substrate utilisation by the heart. To date, the most effective metabolic treatments include several pharmacological agents that directly inhibit fatty acid oxidation. Clinical studies have shown that these agents can substantially increase the ischaemic threshold in patients with effort angina. However, the results of current research is also supporting the concept that shifting the energy substrate preference away from fatty acid metabolism and towards glucose metabolism could be an effective adjunctive treatment in patients with heart failure, in terms of left ventricular function and glucose metabolism improvement. In fact, these agents have also been shown to improve overall glucose metabolism in diabetic patients with left ventricular dysfunction. In this paper, the recent literature on the beneficial therapeutic effects of modulation of cardiac metabolic substrates utilisation in patients with heart failure is reviewed and discussed.

Trimetazidine in the prevention of contrast-induced nephropathy after coronary procedures

OBJECTIVE

To evaluate the efficacy of trimetazidine (TMZ) in the prevention of contrast-induced nephropathy (CIN) in patients with high serum creatinine levels undergoing coronary angiography/angioplasty.

METHODS

TMZ (20 mg thrice daily) was administered orally for 72 h starting 48 h before the procedure. All patients were given intravenous saline (0.9%) at a rate of 1 ml/kg of body weight per hour for 24 h starting 12 h beforehand. Serum creatinine levels were measured before the procedure, 48 h and 7 days after the procedure. Increase in serum creatinine level exceeding 0.5 mg/day or one quarter of the basal value is considered as CIN. Venous blood samples for serum total antioxidant capacity (TAC) measurement were drawn before and after coronary angiography.

RESULTS

Basal serum creatinine levels and TAC were similar in TMZ and control groups. Serum creatinine levels in the control group increased significantly 2 days after the procedure, and returned to the baseline values on the seventh day. However, it did not change significantly on the second day, and even significantly decreased on the seventh day in the TMZ group. CIN developed in 2.5% (1/40) of patients in the TMZ group and in 16.6% (7/42) of patients in the control group (p<0.05). TAC values were not different between treatment groups.

CONCLUSION

TMZ along with isotonic saline infusion is more effective than isotonic saline alone in reducing the risk of CIN in patients with pre-existing renal dysfunction.

Clinical benefits of a metabolic approach in the cardiac rehabilitation of patients with coronary artery disease

Patients referred for cardiac rehabilitation may benefit from combining trimetazidine with exercise training because both treatments produce synergic benefits on the cardiovascular system. There is evidence that trimetazidine improves left ventricular (LV) function in patients with ischemic and diabetic cardiomyopathy by shifting the cellular energy substrate reference from fatty acids to glucose oxidation, and that this effect is associated with a better outcome. Recently, results have demonstrated that trimetazidine improves radial artery endothelium-dependent relaxation related to its antioxidant properties. Similarly, exercise training has been demonstrated to improve diastolic filling and systolic function in patients with ischemic cardiomyopathy, in relation to enhanced perfusion and contractility of dysfunctional myocardium. Patients with viable myocardium, in theory, should have the greatest benefits because trimetazidine improves contractility of dysfunctional hibernating/stunned myocardium, whereas exercise has documented efficacy in improving endothelial vasomotor response of coronary arteries, stimulating coronary collateral circulation and small vessel growth, improving LV function, and increasing functional capacity. At present, there are no published reports about the efficacy of the combination of trimetazidine with exercise training. In this article, we discuss the rationale for using trimetazidine in cardiac rehabilitation, the identification of patients referred for cardiac rehabilitation who might benefit the most from the addition of trimetazidine to standard therapy, and the documented benefits.

Role of trimetazidine in management of ischemic cardiomyopathy

Despite treatment with conventional agents, a high proportion of patients with ischemic cardiomyopathy continue to have symptoms. Moreover, a substantial proportion shows progressive contractile dysfunction leading to left ventricular (LV) enlargement and heart failure. Therefore, a need exists for new treatments for ischemic cardiomyopathy that tackle mechanisms other than those already addressed by conventional agents. Emerging evidence suggests that in patients with ischemic cardiomyopathy, LV dysfunction develops as a result of alterations in substrate metabolism, which contribute to contractile dysfunction and the progression of LV remodeling. Trimetazidine, a novel pharmacologic agent that acts on myocardial metabolic pathways, appears to protect the heart from the deleterious effects of ischemia, and it has been shown to enhance LV contractility in patients with stunned or hibernating myocardium. This article reviews recent clinical trials that have assessed the therapeutic role of trimetazidine in patients with ischemic cardiomyopathy. Trimetazidine has been shown to improve symptoms and LV ejection fraction and to have a beneficial effect on the inflammatory profile and endothelial function in these patients. These results suggest that trimetazidine is a useful adjunct to our current armamentarium for the treatment of patients with ischemic cardiomyopathy.

A randomized clinical trial of trimetazidine, a partial free fatty acid oxidation inhibitor, in patients with heart failure

OBJECTIVES

This study sought to assess whether the long-term addition of trimetazidine to conventional treatment could improve functional class, exercise tolerance, and left ventricular function in patients with heart failure (HF).

BACKGROUND

Previous small studies have shown that trimetazidine may be beneficial in terms of left ventricular function preservation and control of symptoms in patients with post-ischemic HF.

METHODS

Fifty-five patients with HF were randomly allocated in an open-label fashion to either conventional therapy plus trimetazidine (20 mg three times daily) (28 patients) or conventional therapy alone (27 patients). Mean follow-up was 13 +/- 3 months. At study entry and at follow-up, all patients underwent exercise testing and two-dimensional echocardiography. Among the others, New York Heart Association (NYHA) functional class and ejection fraction (EF) were evaluated.

RESULTS

In the trimetazidine group, NYHA functional class significantly improved compared with the conventional therapy group (p < 0.0001). Treatment with trimetazidine significantly decreased left ventricular end-systolic volume (from 98 +/- 36 ml to 81 +/- 27 ml, p = 0.04) and increased EF from 36 +/- 7% to 43 +/- 10% (p = 0.002). On the contrary, in the conventional therapy group, both left ventricular end-diastolic and -systolic volumes increased from 142 +/- 43 ml to 156 +/- 63 ml, p = 0.2, and from 86 +/- 34 ml to 104 +/- 52 ml, p = 0.1, respectively; accordingly, EF significantly decreased from 38 +/- 7% to 34 +/- 7% (p = 0.02).

CONCLUSIONS

In conclusion, long-term trimetazidine improves functional class and left ventricular function in patients with HF. This benefit contrasts with the natural history of the disease, as shown by the decrease of EF in patients on standard HF therapy alone.

The anti-ischemic effect of trimetazidine in patients with postprandial myocardial ischemia is unrelated to meal composition

BACKGROUND

Previous studies provide evidence for a significant reduction of coronary flow reserve after ingestion of meals of different compositions. A possible role of hyperinsulinemia and increased free fatty acid levels, which are deleterious during acute myocardial ischemia and reperfusion, has been hypothesized. We assessed in patients with stable coronary disease the effects of high-fat meals (HFMs) and high-carbohydrate meals (HCMs) on ischemic threshold and stress left ventricular function on placebo and after partial fatty acid inhibition by trimetazidine (TMZ).

METHODS

Ten patients (9 men, age 68 +/- 7 years) were allocated to placebo and TMZ (40 mg TID), both administered in the 24 hours preceding testing, according to a randomized double-blind study design. All patients underwent stress (treadmill exercise testing according to the Bruce protocol) echocardiography after fasting (8 hours) and after an HFM and HCM (2 hours) either on placebo or on TMZ. Time to 1-mm ST-segment depression (time to 1 mm) and stress wall motion score index (WMSI) were evaluated.

RESULTS

An HFM did not affect exercise variables compared with fasting, whereas an HCM resulted in a reduction of the ischemic threshold (time to 1 mm from 402 +/- 141 to 292 +/- 123 seconds, P = .025). Compared with placebo, TMZ improved time to 1 mm after fasting, HFM, and HCM (432 +/- 153 vs 402 +/- 141, 439 +/- 118 vs 380 +/- 107, 377 +/- 123 vs 292 +/- 123, F(1,9) = 26.91, P = .0006). Compared with placebo, on TMZ, stress WMSI decreased from 1.55 +/- 0.25 to 1.29 +/- 0.14 after fasting, from 1.57 +/- 0.10 to 1.39 +/- 0.28 after HFM, and from 1.64 +/- 0.21 to 1.39 +/- 0.21 after HCM (F(1,9) = 37.04, P = .0002). Interestingly, stress WMSI on TMZ was never different from rest WMSI on placebo.

CONCLUSIONS

In patients with coronary disease, exercise testing after an HCM results in more severe myocardial ischemia compared with that after an HFM. The observed beneficial effects of the partial fatty acid inhibitor TMZ seem to be unrelated to meal composition and are possibly caused by the better glucose use induced by the drug.

Placebo or trimetazidine (99m)Tc tetrofosmin myocardial SPECT and low-dose dobutamine echocardiography in hibernating myocardium

BACKGROUND

Trimetazidine (TMZ) improves (99m)Tc sestamibi uptake in myocardial single photon emission tomography (SPECT). This study compared TMZ (99m)Tc tetrofosmin SPECT and low-dose dobutamine echocardiography (LDDE) as predictors of functional recovery of hibernating myocardium after coronary revascularization.

METHODS

Thirty-one patients with prior myocardial infarction and left ventricular dysfunction underwent coronary angiography, LDDE, placebo SPECT and TMZ SPECT. Echocardiographic follow-up was obtained at 2/6 months; the clinical follow-up lasted 2 years.

RESULTS

Twenty-three (74.2%) patients (195 dysfunctioning left ventricular segments) were revascularized. TMZ improved (99m)Tc tetrofosmin uptake (p = 0.0001) as well as LVEF at gated SPECT (p = 0.04). At 2-months, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated (LDDE 71.9, 78.7, 71, 79.5; placebo SPECT 66.2, 75.6, 65.4, 76.3; TMZ SPECT 79.2, 67.7, 61.6, 83.3, respectively). The specificity improved in placebo and TMZ SPECT (82.1 and 78.7%) at 6-months follow-up. Two patients (2/23) with hibernating myocardium treated with revascularization and three (3/4) treated medically died a cardiac death (p = 0.0016, log rank 12.89). None (0/4) without viability died during the 2-year follow-up (p = 0.6, log rank 0.28).

CONCLUSIONS

The addition of TMZ to (99m)Tc tetrofosmin SPECT improved diagnostic accuracy. The importance of hibernating myocardium revascularization was confirmed.

Suppression of angioplasty-related inflammation by pre-procedural treatment with trimetazidine

Percutaneous transluminal coronary angioplasty (PTCA) has been recognized as a reliable treatment procedure for acute reversible ischemia and reperfusion. Ischemic reperfusion cycle in PTCA leads to the systemic inflammation and extensive tissue injury by the production of reactive oxygen species including nitric oxide (NO) radicals. In patients with coronary artery disease, undergoing PTCA, the effects of trimetazidine (TMZ), a piperazine-derivative anti-anginal drug, were studied on several indirect markers of systemic inflammatory response: tumor necrosis factor-alpha (TNF-alpha), C-reactive protein (CRP) and NO products (nitrite and nitrate). Patients (n = 11 each group) were untreated or pre-treated with TMZ (20 mg per orally three times a day), begun three days prior to PTCA, and marker levels were measured before the start of TMZ therapy (baseline), just before PTCA (0 hr), and 4, 24, and 48 hrs after PTCA. The baseline levels of markers were not significantly different between the untreated and pre-treated patients. In contrast, all parameters were lower in the TMZ-treated group than those in the matched control group in the pre- and post-angioplasty periods. Interestingly, in the TMZ group, CRP and nitrite levels were significantly lower than in the control group at each time point of the pre- and post-angioplasty periods, but the TNF-alpha levels were significantly decreased only in the post-angioplasty period. Pre-procedural treatment with oral TMZ for three days significantly suppressed the elevation of inflammatory markers before and shortly after PTCA. We suggest the usefulness of TMZ in preventing inflammatory cardiovascular events after PTCA.

Effects of metabolic modulation by trimetazidine on left ventricular function and phosphocreatine/adenosine triphosphate ratio in patients with heart failure

AIMS

The addition of trimetazidine to standard treatment has been shown to improve left ventricular (LV) function in patients with heart failure. The aim of this study is to non-invasively assess, by means of in vivo 31P-magnetic resonance spectroscopy (31P-MRS), the effects of trimetazidine on LV cardiac phosphocreatine and adenosine triphosphate (PCr/ATP) ratio in patients with heart failure.

METHODS AND RESULTS

Twelve heart failure patients were randomized in a double-blind, cross-over study to placebo or trimetazidine (20 mg t.i.d.) for two periods of 90 days. At the end of each period, all patients underwent exercise testing, 2D echocardiography, and MRS. New York Heart Association (NYHA) class, ejection fraction (EF), maximal rate-pressure product, and metabolic equivalent system (METS) were evaluated. Relative concentrations of PCr and ATP were determined by cardiac 31P-MRS. On trimetazidine, NYHA class decreased from 3.04+/-0.26 to 2.45+/-0.52 (P = 0.005), whereas EF (34+/-10 vs. 39+/-10%, P = 0.03) and METS (from 7.44+/-1.84 to 8.78+/-2.72, P = 0.03) increased. The mean cardiac PCr/ATP ratio was 1.35+/-0.33 with placebo, but was increased by 33% to 1.80+/-0.50 (P = 0.03) with trimetazidine.

CONCLUSION

Trimetazidine improves functional class and LV function in patients with heart failure. These effects are associated to the observed trimetazidine-induced increase in the PCr/ATP ratio, indicating preservation of the myocardial high-energy phosphate levels.