Trimetazidine and Reduction in Mortality and Hospitalization in Patients With Ischemic Dilated Cardiomyopathy: A Post Hoc Analysis of the Villa Pini D'Abruzzo Trimetazidine Trial

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.

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.

Clinical Trials in Hypertrophic Cardiomyopathy Therapy: A Comprehensive Analysis of Trials Registered in Global Clinical Databases

Background

With the disappointing results associated with the use of cardiac myosin inhibitors in the treatment of hypertrophic cardiomyopathy (HCM), the development of new therapies in clinical trials for HCM has rapidly increased. We assessed the characteristics of therapeutic intervention in HCM registered on ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP).

Methods

We conducted a cross-sectional, descriptive study of clinical trials for therapeutic intervention in HCM registered on ClinicalTrials.gov and ICTRP.

Results

This study analyzed 137 registered trials. Regarding study designs of these trials, 77.37% were purpose of treatment, 59.12% were randomized, 50.36% were parallel assignment, 45.26% were performed with masking, 48.18% recruited less than 50 participants, and 27.74% were Phase 2 trials. In total, 67 trials were new drug trials, of which 35 drugs were tested in these trials, and 13 trials involved treatment with mavacamten. Of these 67 clinical drug trials, 44.78% of trials involved the study of amines, and 16.42% involved 1-ring heterocyclic compounds. Regarding the NCI Thesaurus Tree, 23.81% of trials involved myosin inhibitors, 23.81% of trials involved drugs belonging to agents affecting the cardiovascular system, and 20.63% were involved in testing cation channel blockers. The drug-target network showed that myosin-7, potassium voltage-gated channel subfamily h member 2, beta-1 adrenergic receptor, carnitine o-palmitoyltransferase 1, and liver isoform were the most targeted pathways of the clinical trials analyzed in the drug-target network.

Conclusion

The number of clinical trials investigating therapeutic interventions for HCM has increased in recent years. Ultimately, recent HCM therapeutic clinical trials generally did not incorporate either randomized controlled trials or masking and were small studies recruiting fewer than 50 participants. Although recent research has focused on targeting myosin-7, the molecular signaling mechanisms involved in the pathogenesis of HCM have the potential to elucidate novel target pathways.

Effect of trimetazidine on the functional capacity of ischemic heart disease patients not suitable for revascularization: Meta-analysis of randomized controlled trials

Objective

To explore the effect of adding trimetazidine to other anti-anginal drugs on the functional capacity of ischemic heart disease (IHD) patients not suitable for revascularization when compared to first-line antianginal drugs alone.

Methods

MEDLINE and EMBASE databases were searched for English-language peer-reviewed randomized controlled trials (RCTs) comparing trimetazidine with first-line antianginal drugs alone or with placebo in IHD patients not suitable for revascularization and were included in this review. Quality of studies were assessed using the Cochrane collaboration “risk of bias” tool.

Results

Six RCTs, three were crossover studies. A total of 312 participants were included in this review. Overall quality of studies was moderate. Two studies found improvement in the 6-minute walking test (6-MWT) [standardized mean differences (SMD) 1.75; 95% CI 1.35 to 2.14; p <0.001], and two trials found improvement in the Canadian cardiovascular society (CCS) grading of angina class (SMD -1.37; 95% CI -1.89 to -0.84) in the trimetazidine group. Three of the better-quality trials found no increase in total exercise duration (TED) (SMD 0.34; 95% CI -0.10 to 0.78; p < 0.13). Significant heterogeneity was identified among trials describing outcomes for the New York Heart Association (NYHA) functional classification and left ventricular ejection fraction (LVEF %).

Conclusion

Trimetazidine improve walking time and angina severity in IHD patients not suitable for revascularization. Due to the inconsistency of available evidence, RCTs targeting IHD patients with “no option” to undergo coronary revascularization is required to clarify this review question.

Efficacy of trimetazidine - an inhibitor of free fatty acids oxidation in the treatment of patients with stable angina pectoris and heart failure

Aim      To evaluate efficacy of modified-release trimetazidine (TMZ) included into the standard therapy for patients with stable angina and chronic heart failure (CHF) as a part of a subgroup analysis in the PERSPECTIVE study.Material and methods  The study included 806 patients: group 1 (n=691), patients receiving a standard therapy and modified-release TMZ (TMZ group); and group 2 (n=115), patients receiving a standard therapy (control group). Total duration of the study was 12 months.Results In the TMZ group, the weekly number of angina attacks decreased by 41.9% (p&lt;0.0001) in 2 months and by 69.6 % (from baseline, р&lt;0.0001) in 12 months, and the frequency of nitroglycerine dosing decreased by 40.8 % (р&lt;0.0001) and 67.7 % (р&lt;0.0001), respectively. In the control group, the respective values did not change. In the TMZ group compared to the control group, the QT interval was shorter (7.9 %; р&lt;0.05), the left ventricular (LV) end-systolic dimension was reduced (13.4 %; р&lt;0.01), interventricular septal thickness and LV posterior wall thickness were decreased (9.5 %; р&lt;0.01 and 12.2 %; р&lt;0.01, respectively), and the ejection fraction was increased (11.4; р&lt;0.05). Following the TMZ treatment, the leukocyte count in peripheral blood was decreased (5.3 %; р&lt;0.01) and the serum concentration of high-sensitivity C-reactive protein was decreased (30.7 %; р&lt;0.01) vs. increases of these indexes in the control group (17.9 %; р&lt;0.05 and 17.8 %; р&lt;0.05, respectively). The proportion of patients hospitalized for exacerbation of CHF or angina for 12 months was 8.6 % in the TMZ group and 15.7 % in the control group (p=0,001).Conclusion      In patients with stable angina and CHF, inclusion of modified-release TMZ into the standard therapy decreases the number of angina attacks, reduces the activity of inflammatory factors, and improves the course of disease.

Trimetazidine improved adriamycin-induced cardiomyopathy by downregulating TNF-α, BAX, and VEGF immunoexpression via an antioxidant mechanism

Few studies have reported a prophylactic effect of the anti-ischemic trimetazidine (TRI) against cardiac toxicity caused by adriamycin (ADR). However, the mechanism of action of TRI remained incomplete. The cardioprotective mechanism(s) of TRI against ADR-induced cardiotoxicity was investigated in this study. Cardiotoxicity was induced in three groups of Wistar rats by injecting a single dose of ADR (10 mg/kg, i.p.). TRI was administered in two doses regimen, low (L) (2.5 mg/kg, i.p.) and high (H) (10 mg/kg, i.p.). The results of the study showed that both TRI L and H doses improved cardiac enzymes and pathology, while only the TRI H dose improved the electrocardiogram. Both TRI L and H doses decreased malondialdehyde and increased reduced glutathione and superoxide dismutase. Only TRI H dose increased glutathione peroxidase and catalase. Both TRI L and H doses decreased interleukin-1 beta and tumor necrosis factor-alpha (TNF-α). Both TRI L and H doses downregulated TNF-α, BAX, and vascular endothelial growth factor cardiac protein expression. The data obtained in this study provided evidence that TRI opposed ADR-induced cardiotoxicity. The mechanism could be due to improved antioxidant levels as well as inhibition of inflammation and programmed cell death.

Mitochondrial membrane transporters and metabolic switch in heart failure

Mitochondrial dysfunction is widely recognized as a major factor for the progression of cardiac failure. Mitochondrial uptake of metabolic substrates and their utilization for ATP synthesis, electron transport chain activity, reactive oxygen species levels, ion homeostasis, mitochondrial biogenesis, and dynamics as well as levels of reactive oxygen species in the mitochondria are key factors which regulate mitochondrial function in the normal heart. Alterations in these functions contribute to adverse outcomes in heart failure. Iron imbalance and oxidative stress are also major factors for the evolution of cardiac hypertrophy, heart failure, and aging-associated pathological changes in the heart. Mitochondrial ATP-binding cassette (ABC) transporters have a key role in regulating iron metabolism and maintenance of redox status in cells. Deficiency of mitochondrial ABC transporters is associated with an impaired mitochondrial electron transport chain complex activity, iron overload, and increased levels of reactive oxygen species, all of which can result in mitochondrial dysfunction. In this review, we discuss the role of mitochondrial ABC transporters in mitochondrial metabolism and metabolic switch, alterations in the functioning of ABC transporters in heart failure, and mitochondrial ABC transporters as possible targets for therapeutic intervention in cardiac failure.

Medications and Prescribing Patterns as Factors Associated with Hospitalizations from Long-Term Care Facilities: A Systematic Review

BACKGROUND

Residents of long-term care facilities (LTCFs) are at high risk of hospitalization. Medications are a potentially modifiable risk factor for hospitalizations.

OBJECTIVE

Our objective was to systematically review the association between medications or prescribing patterns and hospitalizations from LTCFs.

METHODS

We searched MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and International Pharmaceutical Abstracts (IPA) from inception to August 2017 for longitudinal studies reporting associations between medications or prescribing patterns and hospitalizations. Two independent investigators completed the study selection, data extraction and quality assessment using the Joanna Briggs Institute Critical Appraisal Tools.

RESULTS

Three randomized controlled trials (RCTs), 22 cohort studies, five case-control studies, one case-time-control study and one case-crossover study, investigating 13 different medication classes and two prescribing patterns were included. An RCT demonstrated that high-dose influenza vaccination reduced all-cause hospitalization compared with standard-dose vaccination (risk ratio [RR] 0.93; 95% confidence interval [CI] 0.88-0.98). Another RCT found no difference in hospitalization rates between oseltamivir as influenza treatment and oseltamivir as treatment plus prophylaxis (treatment = 4.7%, treatment and prophylaxis = 3.5%; p = 0.7). The third RCT found no difference between multivitamin/mineral supplementation and hospitalization (odds ratio [OR] 0.94; 95% CI 0.74-1.20) or emergency department visits (OR 1.05; 95% CI 0.76-1.47). Two cohort studies demonstrated influenza vaccination reduced hospitalization. Four studies suggested polypharmacy and potentially inappropriate medications (PIMs) increased all-cause hospitalization. However, associations between polypharmacy (two studies), PIMs (one study) and fall-related hospitalizations were inconsistent. Inconsistent associations were found between psychotropic medications with all-cause and cause-specific hospitalizations (11 studies). Warfarin, nonsteroidal anti-inflammatory drugs, pantoprazole and vinpocetine but not long-term acetylsalicylic acid (aspirin), statins, trimetazidine, digoxin or β-blockers were associated with all-cause or cause-specific hospitalizations in single studies of specific resident populations. Most cohort studies assessed prevalent rather than incident medication exposure, and no studies considered time-varying medication use.

CONCLUSION

High-quality evidence suggests influenza vaccination reduces hospitalization. Polypharmacy and PIMs are consistently associated with increased all-cause hospitalization.

Trimetazidine in the Prevention of Tissue Ischemic Conditions

Trimetazidine (TMZ) is a metabolic agent with significant anti-ischemic properties. By inhibiting the terminal enzyme in the β-oxidation pathway, it shifts the energy substrate metabolism, enhancing glucose metabolism. Thus, it maintains the required energy production with less oxygen consumption, an effect necessary in cases of myocardi. Trimetazidine was recently reaccredited as add-on therapy for symptomatic treatment in patients with stable angina, not adequately controlled or intolerant to first-line therapy. Trimetazidine was included in the European Society of Cardioloy 2013 guidelines for the management of stable coronary artery disease. Although TMZ has been used in cardiology for >40 years, only a few studies have assessed its effects in patients with acute ischemic conditions. This review summarizes the current literature regarding the addition of TMZ in patients with acute ischemic conditions (acute myocardial infarction, ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, percutaneous coronary intervention, and coronary artery bypass grafting). There is growing evidence from recent studies that the addition of TMZ in patients with such conditions is beneficial in terms of myocardial damage and major cardiac events as well as decreasing reperfusion injury and contrast-induced nephropathy.

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.

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.

Trimetazidine prevents macrophage-mediated septic myocardial dysfunction via activation of the histone deacetylase sirtuin 1

BACKGROUND AND PURPOSE

Sepsis is a systemic inflammatory response accompanied by excessive production of inflammatory cytokines and cardiovascular dysfunction. Importantly, macrophage-derived pro-inflammatory agents play a key role in cardiovascular impairment in sepsis. Here we have investigated the effects of trimetazidine (TMZ) on pro-inflammatory responses of macrophages in endotoxin-induced myocardial dysfunction.

EXPERIMENTAL APPROACH

Mice pretreated with TMZ were injected i.p. with LPS and cardiac function evaluated. Levels of macrophage infiltration, macrophage inflammatory response and cardiomyocyte apoptosis were measured using immunohistochemical staining, elisa, real-time RT-PCR, Western blot, TUNEL and flow cytometry assays.

KEY RESULTS

Pretreatment with TMZ prevented LPS-induced myocardial dysfunction and apoptosis. TMZ also lowered levels of pro-inflammatory cytokines in serum and cardiac tissue and myocardial macrophage infiltration. Bone marrow transplantation indicated that TMZ alleviated LPS-induced myocardial dysfunction via decreasing macrophage infiltration. TMZ reduced expression of pro-inflammatory cytokines in LPS-stimulated cardiac and peritoneal macrophages. Co-culture of TMZ-pretreated macrophages with cardiomyocytes and conditioned media from TMZ-pretreated macrophages both decreased LPS-induced cardiomyocyte apoptosis. The anti-apoptosis effects of TMZ resulted from decrease of pro-inflammatory cytokines, partly due to normalizing the sirtuin 1 (Sirt1)/AMP-activated protein kinase (AMPK)/Nrf2/haem oxygenase-1 and Sirt1/PPARα pathways in macrophages. Cytokine secretion was also regulated by ROS, which were attenuated by TMZ via activation of Sirt1, AMPK and PPARα.

CONCLUSIONS AND IMPLICATIONS

TMZ protected against LPS-induced myocardial dysfunction and apoptosis, accompanied by inhibition of macrophage pro-inflammatory responses. Our studies suggest that TMZ might represent a novel therapeutic agent to prevent and treat sepsis-induced myocardial dysfunction.

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.

The effect of trimetazidine added to pharmacological treatment on all-cause mortality in patients with systolic heart failure

The anti-ischemic agent trimetazidine (TMZ) added to pharmacological treatment appears to have positive effects on cardiac parameters of patients with heart failure (HF) as a result of specific antioxidant properties.

OBJECTIVES

We aimed to verify whether the marked improvement provided by TMZ in echocardiographic and clinical parameters was likely to translate into reduced all-cause mortality in systolic HF patients.

METHODS

Meta-analysis of available published prospective randomized controlled trial (RCT) data (1967-2014) retrieved from PubMed, Web of Science and Cochrane Collaboration.

RESULTS

A total of 326 patients from 3 RCTs were analyzed: 164 who received TMZ on top of pharmacological HF therapy and 162 controls. Study durations ranged from 12 to 48 months. The analysis had no publication bias and the studies were homogeneous (p = 0.442, I(2) = 0). The results show a significant effect of TMZ on the reduction of all-cause mortality (RR = 0.283, p < 0.0001). The rate of events attributable to the drug was lower with TMZ than it was among control patients.

CONCLUSION

This meta-analysis suggests that in patients with HF, TMZ given as an add-on therapy is likely to provide a protective effect, reduce all-cause mortality and increase event-free survival, and could be an effective and useful adjunct to our armamentarium for the treatment of HF patients.

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.

The effect of trimetazidine on cardiac function in diabetic patients with idiopathic dilated cardiomyopathy

AIMS

Trimetazidine is an anti-ischemic metabolic agent which improves myocardial glucose utilization. Whether it may improve cardiac function and physical tolerance in diabetic patients with idiopathic dilated cardiomyopathy is still not confirmed. In this study we have investigated the effectiveness of trimetazidine in these patients.

MAIN METHODS

Volunteers with diabetes and idiopathic dilated cardiomyopathy were recruited for participation in this study. Patients were randomized into two groups. One group received trimetazidine (20mg, t.i.d.) for 6 months (n=40), while another group received a placebo during the same period (n=40). All patients received an echocardiographic examination, 6-minute walk test and an inflammation biochemical analysis (C reactive protein) at baseline and after 6 months of treatment.

KEY FINDINGS

No significant adverse events or changes in clinical or biochemical parameters were detected through the study. After 6 months, TMZ-treated patients had a significant improvement in systolic function as compared with control patients associated with an increased ratio of E/A. C reactive protein concentrations remained stable throughout the study in trimetazidine group at baseline and at the 6 month on follow up. In comparison, it increased significantly in the control group at the 6-month follow up. The NT-pro BNP levels did not change in the control group, whereas they significantly decreased in the trimetazidine group. The physical activity tolerance level improved in the trimetazidine group compared to the control group.

SIGNIFICANCE

Trimetazidine treatment was associated with a significant improvement of cardiac function and physical tolerance. Results also suggested that the inflammatory response was decreased in trimetazidine group as compared with control patients.

New potential of Trimetazidine MB for coronary heart disease treatment in the real-world clinical practice: results of the Russian multi-centre randomised study PERSPECTIVE (Part II)

Aim. As a clinical part of the Russian multi-centre randomised study, to assess the clinical benefits and safety of adding Trimetazidine MB to the standard treatment scheme in patients with stable angina (SA), in order to optimise their ambulatory therapy and improve their compliance. Material and methods. The study included 981 patients with Functional Class (FC) II-III SA and various concomitant diseases and syndromes, such as chronic heart failure (CHF), Type 2 diabetes mellitus (DM-2), or chronic obstructive pulmonary disease (COPD) in smokers. All participants were divided into two groups: Group I (n=838) received standard therapy plus trimetazidine MB (70 mg/d, twice a day), while Group II (n=143) received standard therapy only. The treatment and follow-up phases lasted for 12 months. Results. In Group I, the weekly number of angina attacks decreased by 42 % from the baseline at one month (р<0,0001), and by 70 % at 12 months (р<0,0001). The number of nitroglycerin (NTG) tablets taken decreased, respectively, by 41 % (р<0,0001) and 68 % (р<0,0001). In Group II, the decrease in angina attack number and NTG tablet number was significant only at 6 months and was less pronounced than in Group I. Therefore, in Group I, the number of patients with FC I increased by 7 times, while the number of FC III patients decreased by 1,8 times. No marked FC dynamics was observed in Group II. In Group I, left ventricular ejection fraction (LVEF) increased by 2,4 % (р<0,001), while interventricular septum and LV posterior wall thickness decreased, respectively, by 4,2 % (р<0,01) and 3,5 % (р<0,01). These parameters, however, did not change substantially in Group II patients. At 12 months, the number of patients hospitalised due to clinical decompensation, or becoming disable, was twice as high in Group II as in Group I. Conclusion. The Russian “PERSPECTIVE” Study results demonstrated high clinical effectiveness and safety ofTrimetazidineMB therapy, combined with standard treatment, in SA patients with CHF, DM-2, and COPD. Therefore, metabolic therapy could be more widely used in the real-world clinical settings.

Use of inotropic agents in patients with advanced heart failure: lessons from recent trials and hopes for new agents

Abnormalities of cardiac function, with high intraventricular filling pressure and low cardiac output, play a central role in patients with heart failure. Agents with inotropic properties are potentially useful to correct these abnormalities. However, with the exception of digoxin, no inotropic agent has been associated with favourable effects on outcomes. This is likely related to the mechanism of action of current agents, which is based on an increase in intracellular cyclic adenosine monophosphate and calcium concentrations. Novel agents acting through different mechanisms, such as sarcoplasmic reticulum calcium uptake, cardiac myosin and myocardial metabolism, have the potential to improve myocardial efficiency and lower myocardial oxygen consumption. These characteristics might allow a haemodynamic improvement in the absence of untoward effects on the clinical course and prognosis of the patients.

Pharmacological strategies against cold ischemia reperfusion injury

IMPORTANCE OF THE FIELD

Good organ preservation is a determinant of graft outcome after revascularization. The necessity of increasing the quality of organ preservation, as well as of extending cold storage time, has made it necessary to consider the use of pharmacological additives.

AREAS COVERED IN THIS REVIEW

The complex physiopathology of cold-ischemia-reperfusion (I/R) injury--and in particular cell death, mitochondrial injury and endoplasmic reticulum stress--are reviewed. Basic principles of the formulation of the different preservation solutions are discussed.

WHAT THE READER WILL GAIN

Current strategies and new trends in static organ preservation using additives such as trimetazidine, polyethylene glycols, melatonin, trophic factors and endothelin antagonists in solution are presented and discussed. The benefits and mechanisms responsible for enhancing organ protection against I/R injury are also discussed. Graft preservation was substantially improved when additives were added to the preservation solutions.

TAKE HOME MESSAGE

Enrichment of preservation solutions by additives is clinically useful only for short periods. For longer periods of cold ischemia, the use of such additives becomes insufficient because graft function deteriorates as a result of ischemia. In such conditions, the preservation strategy should be changed by the use of machine perfusion in normothermic conditions.

Metabolic modulation and cellular therapy of cardiac dysfunction and failure

At present the prevalence of heart failure rises along with aging of the population. Current heart failure therapeutic options are directed towards disease prevention via neurohormonal antagonism (β-blockers, angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers and aldosterone antagonists), symptomatic treatment with diuretics and digitalis and use of biventricular pacing and defibrillators in a special subset of patients. Despite these therapies and device interventions heart failure remains a progressive disease with high mortality and morbidity rates. The number of patients who survive to develop advanced heart failure is increasing. These patients require new therapeutic strategies. In this review two of emerging therapies in the treatment of heart failure are discussed: metabolic modulation and cellular therapy. Metabolic modulation aims to optimize the myocardial energy utilization via shifting the substrate utilization from free fatty acids to glucose. Cellular therapy on the other hand has the goal to achieve true cardiac regeneration. We review the experimental data that support these strategies as well as the available pharmacological agents for metabolic modulation and clinical application of cellular therapy.

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.