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Effectiveness and Tolerability of Trimetazidine 80 Mg Once Daily in Patients with Stable Angina Uncontrolled with Bisoprolol-Based Therapy: The Modus Vivendi Observational Study. Cardiol Ther 2021; 11:93-111. [PMID: 34958427 PMCID: PMC8933606 DOI: 10.1007/s40119-021-00249-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/26/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Modus Vivendi was conducted in routine clinical practice to evaluate the effect of adding trimetazidine 80 mg once daily (TMZ 80 OD) to treat patients with persistent symptoms despite treatment with background antianginal therapies including maximally tolerated bisoprolol. Methods This multicenter, prospective, observational, open-label, uncontrolled study recruited adult outpatients with a confirmed diagnosis of stable angina to whom physicians had decided to prescribe TMZ 80 OD. All patients were symptomatic despite treatment, including maximally tolerated doses of bisoprolol. Data on number of angina attacks, use of short-acting nitrates, and quality of life (QoL) were collected at baseline (V1) and at 1-month (V2) and 3-month (V2) follow-up visits. Two sub-analyses assessed efficacy in patients who remained on a stable bisoprolol dose throughout the study, and in patients in whom background antianginal therapy was known. Results A total of 1939 patients were recruited (57.2% women). The mean age was 65.6 ± 8.8 years; 73.8% had class II and 26.2% class III angina. At V1, the mean number of angina attacks per week was 6.2 ± 6.5 despite antianginal therapy including maximally tolerated bisoprolol dosage. Following the addition of TMZ 80 OD, this decreased to 3.4 ± 4.2 attacks per week at V2, and 1.6 ± 2.6 at V3 (P < 0.05 at V2 and V3), with concomitant reductions in short-acting nitrate use (P < 0.05). Significant improvements in QoL were observed throughout the study. Subgroup analyses showed that the addition of TMZ 80 OD to guideline-recommended antianginal therapy was associated with significant reductions in the mean number of weekly angina attacks and consumption of short-acting nitrates and improvements in QoL whether patients were treated with maximally tolerated bisoprolol and TMZ 80 OD alone, or maximally tolerated bisoprolol and TMZ 80 OD on top of other antianginal therapies. Treatment was well tolerated. Conclusion The study findings support the addition of TMZ 80 OD to bisoprolol with or without other antianginal therapies for patients with persistent angina. Trial Registration This study was retrospectively registered under the number ISRCTN29992579.
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Khedr A, Neupane B, Proskuriakova E, Jada K, Kakieu Djossi S, Mostafa JA. Pharmacologic Management of Coronary Artery Ectasia. Cureus 2021; 13:e17832. [PMID: 34660041 PMCID: PMC8502747 DOI: 10.7759/cureus.17832] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 09/08/2021] [Indexed: 01/24/2023] Open
Abstract
Coronary artery ectasia (CAE) is a rare form of aneurysmal coronary heart disease. It is defined as a dilatation of the coronary artery by more than one-third of its length and with a diameter 1.5 times of a normal coronary artery adjacent to it. This condition increases the risk of angina pectoris and acute coronary syndrome. Hence, we discuss the pharmacologic options for primary and secondary prevention of CAE complications. Antiplatelets such as aspirin are considered the mainstay of treatment in patients with CAE. Anticoagulants such as warfarin are warranted on a case-by-case basis to prevent thrombus formation depending on the presence of concomitant obstructive coronary artery disease and the patient’s risk of bleeding. Since atherosclerosis is the most common cause of CAE, statins are indicated in all patients for primary prevention. Angiotensin-converting enzyme (ACE) inhibitors may be indicated, especially in hypertensive patients, due to their anti-inflammatory properties. Beta-blockers may be indicated due to their antihypertensive and anti-ischemic effects. Calcium (Ca) channel blockers may be needed to prevent coronary vasospasm. Nitrates are generally contraindicated as they may lead to worsening of symptoms. Other antianginal medications such as trimetazidine can improve exercise tolerance with no reported adverse events in these patients.
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Affiliation(s)
- Anwar Khedr
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Bandana Neupane
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ekaterina Proskuriakova
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Keji Jada
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Jihan A Mostafa
- Psychiatry, Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Manolis AJ, Boden WE, Collins P, Dechend R, Kallistratos MS, Lopez Sendon J, Poulimenos LE, Ambrosio G, Rosano G. State of the art approach to managing angina and ischemia: tailoring treatment to the evidence. Eur J Intern Med 2021; 92:40-47. [PMID: 34419311 DOI: 10.1016/j.ejim.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/24/2021] [Accepted: 08/07/2021] [Indexed: 10/20/2022]
Abstract
Stable angina represents a chronic and often debilitating condition that affects daily activities and quality of life in patients with chronic coronary syndromes (CCS). Current European Society of Cardiology guidelines recommend a four-step approach for the medical treatment of patients taking into consideration hemodynamic variables (heart rate and blood pressure) and the presence or absence of left ventricular dysfunction. However, CCS patients often have several comorbidities and risk factors. Thus, a tailored approach that takes into consideration patient risk factors and comorbidities may have additional benefits beyond angina relief. This is a state of the art review of stable angina treatment based on the currently available evidence.
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Affiliation(s)
- A J Manolis
- Asklepeion General Hospital, Cardiology Department, Athens, Greece; Metropolitan General Hospital, Cardiology Department, Athens, Greece.
| | - W E Boden
- Department of Medicine, VA Boston Healthcare System, West Roxbury, Massachusetts, USA; Boston University School of Medicine, Boston, Massachusetts, USA
| | - P Collins
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, United Kingdom
| | - R Dechend
- Experimental and Clinical Research Center, a joint cooperation between Max-Delbruck Center for Molecular Medicine and Charité - Universitatsmedizin Berlin and HELIOS Clinic Department of Cardiology and Nephrology, Germany
| | - M S Kallistratos
- Asklepeion General Hospital, Cardiology Department, Athens, Greece
| | - J Lopez Sendon
- Servicio de Cardiología, Hospital Universitario La Paz, Instituto de Investigación La Paz (IdiPAZ), Madrid, Spain
| | - L E Poulimenos
- Asklepeion General Hospital, Cardiology Department, Athens, Greece
| | - G Ambrosio
- Division of Cardiology University of Perugia School of Medicine, Italy
| | - G Rosano
- St George's Hospitals NHS Trust University of London - IRCCS San Raffaele Roma, Italy
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With a grain of salt: Sodium elevation and metabolic remodelling in heart failure. J Mol Cell Cardiol 2021; 161:106-115. [PMID: 34371034 PMCID: PMC7611640 DOI: 10.1016/j.yjmcc.2021.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 07/09/2021] [Accepted: 08/03/2021] [Indexed: 12/14/2022]
Abstract
Elevated intracellular Na (Nai) and metabolic impairment are interrelated pathophysiological features of the failing heart (HF). There have been a number of studies showing that myocardial sodium elevation subtly affects mitochondrial function. During contraction, mitochondrial calcium (Camito) stimulates a variety of TCA cycle enzymes, thereby providing reducing equivalents to maintain ATP supply. Nai elevation has been shown to impact Camito; however, whether metabolic remodelling in HF is caused by increased Nai has only been recently demonstrated. This novel insight may help to elucidate the contribution of metabolic remodelling in the pathophysiology of HF, the lack of efficacy of current HF therapies and a rationale for the development of future metabolism-targeting treatments. Here we review the relationship between Na pump inhibition, elevated Nai, and altered metabolic profile in the context of HF and their link to metabolic (in)flexibility and mitochondrial reprogramming.
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Cosentino F, Grant PJ, Aboyans V, Bailey CJ, Ceriello A, Delgado V, Federici M, Filippatos G, Grobbee DE, Hansen TB, Huikuri HV, Johansson I, Jüni P, Lettino M, Marx N, Mellbin LG, Östgren CJ, Rocca B, Roffi M, Sattar N, Seferović PM, Sousa-Uva M, Valensi P, Wheeler DC. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J 2021; 41:255-323. [PMID: 31497854 DOI: 10.1093/eurheartj/ehz486] [Citation(s) in RCA: 2301] [Impact Index Per Article: 767.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Glezer M. Trimetazidine and Bisoprolol to Treat Angina in Symptomatic Patients: Post Hoc Analysis From the CHOICE-2 Study. Cardiol Ther 2020; 10:161-173. [PMID: 33247333 PMCID: PMC8126526 DOI: 10.1007/s40119-020-00202-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Indexed: 01/09/2023] Open
Abstract
Introduction Angina is the cardinal symptom of chronic coronary syndrome (CCS), which is the leading cause of death worldwide. As such, the control of angina is important. The current guidelines recommend beta blockers (BB) or calcium channel blockers to reduce angina, yet many patients with stable angina remain symptomatic. It has been suggested that combining trimetazidine (TMZ), an anti-ischemic agent, with a BB is beneficial for symptomatic patients. Bisoprolol, a BB, is often used to treat patients with CCS, yet no data are currently available regarding the efficacy of bisoprolol combined with TMZ in patients who remain symptomatic despite receiving bisoprolol. Methods The aim of this post-hoc analysis of the CHOICE-2 study was to evaluate the efficacy and safety of TMZ 35 mg twice daily in combination with different bisoprolol doses in symptomatic patients with stable angina patients receiving hemodynamic therapy in a real-world clinical setting. Results This analysis involved 221 patients (mean [± standard deviation] age 64.8 ± 8.9 years) with stable angina. The mean number of weekly angina episodes gradually fell from 6.2 ± 5.3 at inclusion (M0) to 1.5 ± 1.9 at 6 months after treatment initiation (M6) with combined TMZ–bisoprolol therapy (P < 0.001). The number of patients assessed to be angina-free increased almost sixfold from 5.4% (12/221) at M0 to 33.9% (74/221) at M6. Exercise capacity improved, as measured by walking distance, from 308 ± 207 m at M0 to 497 ± 253 m at M6 (P < 0.05). The number of patients with Canadian Cardiovascular Society class 1 angina increased by tenfold during the study, whereas those with class 3 angina decreased by threefold. Conclusion The TMZ–bisoprolol combination is a rapidly effective treatment for reducing the frequency of angina attacks and the use of short-acting nitrates in patients with stable angina in a real-world clinical setting. The benefits of this combination therapy was observed as early as 2 weeks after treatment initiation and the treatment was well tolerated. Trial Registration ISRCTN identifier: ISRCTN65209863
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Affiliation(s)
- Maria Glezer
- Department of Cardiology, Functional and Ultrasound Diagnostics, Sechenov First Moscow State Medical University, Moscow, Russia.
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Fu H, Zhang J, Zhang H, Zhang P, Fu X, Zeng Z, Zhang X, Li W, Yang S, Liu X, Fu N. Trimetazidine can prevent the occurrence of contrast-induced nephropathy after percutaneous coronary intervention in elderly patients with renal insufficiency. Perfusion 2020; 36:603-609. [PMID: 32909511 DOI: 10.1177/0267659120957856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Contrast-induced nephropathy (CIN) has become a common cause of hospital-acquired acute kidney injury in elderly patients. Trimetazidine (TMZ) is a type of anti-ischemic drug developed in recent years, which can reduce the incidence of CIN. This study aimed to evaluate the efficacy of TMZ in the prevention of contrast-induced nephropathy in elderly patients with renal insufficiency undergoing percutaneous coronary intervention (PCI) and to explore the mechanism of action. METHODS A total of 310 elderly patients with renal insufficiency undergoing elective PCI were enrolled and randomly assigned to a control group (n = 155, hydration only) and a TMZ group (n = 155, 20 mg thrice daily orally 24 hours before and 72 hours after PCI). The primary endpoint of the study was the incidence of CIN, which was defined as an increase of 25% or more, or an absolute increase of 0.5 mg/dL or more in serum creatinine from baseline value, at 48 to 72 hours following the exposure to contrast media (CM). RESULTS The incidence of CIN was significantly lower in the TMZ group than that in the control group (3.2% vs. 9.7%, p = 0.021). There was no difference regarding the incidence of major adverse events during hospitalization between the TMZ group and control group (1.9% vs. 2.6%, p = 1.000). Binary logistic regression results showed that TMZ was protective factors of CIN (OR = 0.274; 95% CI: 0.089-0.847; p = 0.025). CONCLUSION Therefore, we came to the conclusion that prophylactic administration of TMZ can prevent the occurrence of CIN in elderly patients with renal insufficiency undergoing PCI and has a certain protective effect on the renal function of patients. According to the experimental results and the mechanism of TMZ on cardiomyocytes, we speculate that TMZ increases kidney glucose metabolism, reduces fatty acid oxidation, and also has a protective effect on kidney free radical damage and ischemia-reperfusion injury.
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Affiliation(s)
- Han Fu
- Tianjin Medical University, Tianjin, China
| | | | | | | | | | | | - Xue Zhang
- Tianjin Medical University, Tianjin, China
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Lu S, Yu L, Liu H. Trimetazidine alleviates hypoxia/reoxygenation-induced apoptosis in neonatal mice cardiomyocytes via up-regulating HMGB1 expression to promote autophagy. J Recept Signal Transduct Res 2020; 41:170-179. [PMID: 32757698 DOI: 10.1080/10799893.2020.1800736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Previous studies demonstrated the effect of Trimetazidine (TMZ) on alleviating cardiomyocytes Hypoxia/Reoxygenation (H/R) injuries and the protective effect of autophagy on Ischemia-Reperfusion (I/R) cell injuries. However, whether the protection mechanism of TMZ was also involved in autophagy remained unclear. Our study introduces the role of HMGB1 to examine the regulation of TMZ on autophagy against cardiomyocytes H/R injuries. After cell extraction and identification through anti-α-actin staining, the cardiomyocytes were made hypoxic and reoxygenated, each for 3 h, and then treated with various concentrations of TMZ and transfected with siHMGB1. Cell viability and apoptosis were measured by the MTS method and flow cytometry, respectively. The expressions of autophagy-related factors (LC3-I, LC3-II, Beclin-1) and HMGB1 were detected by Western blot and qPCR. Lactate dehydrogenase (LDH) release was assessed by ELISA kit. The cardiomyocytes were extracted. H/R decreased the cell viability and increased the LDH level and apoptosis of cardiomyocytes. TMZ had no effect on untreated cardiomyocytes, but it reversed the adverse impact of H/R on cardiomyocytes. The expressions of LC3-II, Beclin-1, and HMGB1 and the ratio of LC3-II/LC3-I were increased in H/R-processed cardiomyocytes and further raised by TMZ pretreatment. However, siHMGB1 transfection aggravated the impact of H/R on cardiomyocytes and suppressed the protective effects of TMZ on H/R damaged cardiomyocytes by increasing the LDH level and apoptosis and reducing the viability of cardiomyocytes. Autophagy was inhibited by siHMGB1 in TMZ-pretreated and H/R-processed cardiomyocytes. TMZ protected cardiomyocytes against H/R injuries may through regulating HMGB1 to increase the impact of autophagy.
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Affiliation(s)
- Shiwen Lu
- Department of Cardiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lifei Yu
- Department of Cardiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Hao Liu
- Department of Cardiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
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9
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Ferrari R, Pavasini R, Camici PG, Crea F, Danchin N, Pinto F, Manolis A, Marzilli M, Rosano GMC, Lopez-Sendon J, Fox K. Anti-anginal drugs-beliefs and evidence: systematic review covering 50 years of medical treatment. Eur Heart J 2020; 40:190-194. [PMID: 30165445 DOI: 10.1093/eurheartj/ehy504] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/23/2018] [Indexed: 11/14/2022] Open
Abstract
Chronic stable angina is the most prevalent symptom of ischaemic heart disease and its management is a priority. Current guidelines recommend pharmacological therapy with drugs classified as being first line (beta blockers, calcium channel blockers, short acting nitrates) or second line (long-acting nitrates, ivabradine, nicorandil, ranolazine, and trimetazidine). Second line drugs are indicated for patients who have contraindications to first line agents, do not tolerate them or remain symptomatic. Evidence that one drug is superior to another has been questioned. Between January and March 2018, we performed a systematic review of articles written in English over the past 50 years English-written articles in Medline and Embase following preferred reporting items and the Cochrane collaboration approach. We included double blind randomized studies comparing parallel groups on treatment of angina in patients with stable coronary artery disease, with a sample size of, at least, 100 patients (50 patients per group), with a minimum follow-up of 1 week and an outcome measured on exercise testing, duration of exercise being the preferred outcome. Thirteen studies fulfilled our criteria. Nine studies involved between 100 and 300 patients, (2818 in total) and a further four enrolled greater than 300 patients. Evidence of equivalence was demonstrated for the use of beta-blockers (atenolol), calcium antagonists (amlodipine, nifedipine), and channel inhibitor (ivabradine) in three of these studies. Taken all together, in none of the studies was there evidence that one drug was superior to another in the treatment of angina or to prolong total exercise duration. There is a paucity of data comparing the efficacy of anti-anginal agents. The little available evidence shows that no anti-anginal drug is superior to another and equivalence has been shown only for three classes of drugs. Guidelines draw conclusions not from evidence but from clinical beliefs.
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Affiliation(s)
- Roberto Ferrari
- Cardiology Centre, University of Ferrara, Via Aldo Moro 8, Cona, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Via Corriera 1, Cotignola, Ravenna, Italy
| | - Rita Pavasini
- Cardiology Centre, University of Ferrara, Via Aldo Moro 8, Cona, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Via Corriera 1, Cotignola, Ravenna, Italy
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Via Olgettina Milano, 58-60, Milano, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Catholic University, Largo Francesco Vito, 1, Roma, Italy
| | - Nicolas Danchin
- Cardiology, European Hospital Georges-Pompidiou, 20 Rue Leblanc, Paris, France
| | - Fausto Pinto
- Lisbon University, Faculty of Medicine, Lisbon, Portugal
| | - Athanasios Manolis
- Department of Cardiology, Asklepeion General Hospital, 1 Vas. Pavlou Street, Voula Athens, Greece
| | - Mario Marzilli
- Cardiothoracic Department, Lugarno Antonio Pacinotti, 43, Pisa, Italy.,Nottola Cardiology Division, Località Nottola, Ospedali Riuniti Valdichiana Sudest, Siena, Italy
| | - Giuseppe M C Rosano
- Clinical Academic Group, St George's Hospital NHS Trust, University of London, Blackshaw Rd, London, UK.,Department of Medical Science IRCCS San Raffaele Rome, via della Pisana 235, Rome, Italy
| | - José Lopez-Sendon
- Cardiology Department, Hospital Universitario La Paz. IdiPaz, Universidad Aut?noma de Madrid, Paseo de la Castellana 261, Madrid, Spain
| | - Kim Fox
- National Heart and Lung Institute, Imperial College and Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, Sydney Street, London, UK
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Guía ESC 2019 sobre diabetes, prediabetes y enfermedad cardiovascular, en colaboración con la European Association for the Study of Diabetes (EASD). Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.11.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Seecheran N, Seebalack V, Seecheran R, Maharaj A, Boodhai B, Seecheran V, Persad S, Motilal S, Tello-Montoliu A, Schneider D. TRimetazidine as an Agent to affeCt clopidogrEl Response: The TRACER Study. Cardiol Ther 2019; 8:229-237. [PMID: 31292901 PMCID: PMC6828882 DOI: 10.1007/s40119-019-0139-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION This prospective study aimed to determine whether trimetazidine (TMZ) alters the pharmacodynamic (PD) effects of clopidogrel. METHODS Patients with stable coronary artery disease (SCAD) (n = 24) who were actively treated with dual antiplatelet therapy (DAPT) of aspirin 81 mg daily and clopidogrel 75 mg daily were recruited. Platelet function was measured with the VerifyNow P2Y12 assay (Accriva Diagnostics, San Diego, CA, USA) and assessed before the initiation of and after 14 days of treatment with TMZ. Results were compared using a paired t test. RESULTS Almost 80% of the study population were of South Asian descent and had diabetes mellitus (DM). P2Y12 reaction units (PRUs) were higher in patients on TMZ (204 ± 56 compared with 174 ± 71 before TMZ, p = 0.005). The average increase in PRU score was 29 (95% confidence interval 8.8-49.7). Before TMZ, the proportion of patients with high on-treatment platelet reactivity (PRU > 208 units) was 25%, which increased to 42% for patients on TMZ. CONCLUSION Higher platelet reactivity was seen in patients on TMZ, suggesting that TMZ attenuated the PD effects of clopidogrel in this study of a predominantly South Asian diabetic subpopulation. Alternative therapies should be considered and further research is warranted. TRIAL REGISTRATION ClinicalTrials.gov number, NCT03603249.
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Affiliation(s)
- Naveen Seecheran
- Department of Clinical Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago.
| | - Victoria Seebalack
- Department of Clinical Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Rajeev Seecheran
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Aarti Maharaj
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Brent Boodhai
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Valmiki Seecheran
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Sangeeta Persad
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Shastri Motilal
- Department of Clinical Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | | | - David Schneider
- Cardiovascular Research Institute of Vermont, Colchester, VT, USA
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Glezer MG, Vygodin VA. Effectiveness of Long-acting Trimetazidine in Different Clinical Situations in Patients with Stable Angina Pectoris: Findings from ODA Trial. Cardiol Ther 2019; 8:69-78. [PMID: 30778909 PMCID: PMC6525211 DOI: 10.1007/s40119-019-0128-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Indexed: 12/21/2022] Open
Abstract
Introduction Trimetazidine (TMZ) has been shown to be efficacious for angina treatment. The TMZ 80-mg formulation allows one-daily (od) dosage, which could improve symptom control and adherence. Methods The 3-month, observational, multicenter, prospective ODA (antianginal effectiveness and tolerability of trimetazidine modified release 80 mg Once Daily in stable Angina patients in real-world practice) study assessed TMZ 80 mg od effectiveness in stable angina patients with persistent symptoms despite therapy. Two clinical situations were compared: patients who initiated treatment with TMZ 80 mg od (initiation group) and patients who were previously treated with TMZ 20 mg thrice daily (tid) or TMZ 35 mg MR twice daily (bid) and switched to TMZ 80 mg od (switch group). Number of angina attacks, short-acting nitrate (SAN) consumption, self-reported patient daily activity, Canadian Cardiovascular Society (CCS) class, adherence to antianginal therapy, overall efficacy and tolerability were assessed. Results A significant decrease in weekly number of angina attacks was observed for both the initiation group (n = 1841 patients) from 4.8 ± 3.5 at baseline to 0.9 ± 1.4 at 3 months (M3) (P < 0.001), and the switch group (n = 1216 patients) from 4.4 ± 1.3 at baseline to 0.9 ± 1.3 at M3 (P < 0.001). Significant reduction in SAN consumption and improvement in CCS class were observed for both groups. Adherence to antianginal therapy improved in both groups at 1 month (M1) and M3. Overall effectiveness of TMZ 80 mg od was rated by physicians as “very good” (68% initiation group, 70% switch group), “good” (31% initiation group, 29% switch group), “moderate” (1%, both groups) or “poor” (< 1%, both groups). Overall tolerability of TMZ 80 mg od was rated by physicians as “very good” (75%), “good” (25%) or “moderate” (< 1%) in both groups. Conclusions TMZ 80 mg od, in association with other antianginal therapy, effectively reduced angina attacks and SAN consumption and improved physical activity and adherence to antianginal therapy both in patients initiating TMZ treatment and those switching from a bid or tid formulation. Trial Registration ISRCTN registry Identifier, ISRCTN97780949. Funding Servier. Plain Language Summary Plain language summary available for this article. Electronic supplementary material The online version of this article (10.1007/s40119-019-0128-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maria G Glezer
- Department of Preventive and Emergency Cardiology, Sechenov First Moscow State Medical University, Moscow, Russia.
| | - Vladimir A Vygodin
- Laboratory of Biostatistics, National Medical Research Center for Preventive Medicine of the Ministry of Healthcare, Moscow, Russia
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Pavasini R, Camici PG, Crea F, Danchin N, Fox K, Manolis AJ, Marzilli M, Rosano GMC, Lopez-Sendon JL, Pinto F, Balla C, Ferrari R. Anti-anginal drugs: Systematic review and clinical implications. Int J Cardiol 2018; 283:55-63. [PMID: 30538056 DOI: 10.1016/j.ijcard.2018.12.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/17/2018] [Accepted: 12/03/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The cornerstone of the treatment of patients affected by stable angina is based on drugs administration classified as first (beta-blockers, calcium channel blockers, short acting nitrates) or second line treatment (long-acting nitrates, ivabradine, nicorandil, ranolazine and trimetazidine). However, few data on comparison between different classes of drugs justify that one class of drugs is superior to another. METHODS We performed a systematic review of the literature following PRISMA guidelines. INCLUSION CRITERIA i) paper published in English; ii) diagnosis of stable coronary disease; iii) randomized clinical trial; iv) comparison of two anti-angina drugs; v) a sample size >100 patients; vi) a follow-up lasting at least 2 weeks; vii) paper published after 1999, when a meta-analysis of trials comparing beta-blockers, calcium antagonists, and nitrates for stable angina of Heidenreich et al. was published. OUTCOME to establish whether the categorization in first and second line antianginal treatment is scientifically supported. RESULTS Eleven trials fulfilled inclusion criteria. The results show that there is a paucity of data comparing the efficacy of antianginal agents. The little data available show that there are not compounds superior to others in terms of improvement in exercise test duration, frequency of anginal attacks, need for sub-lingual nitroglycerin. CONCLUSION The categorization of antianginal drug in first and second line is not confirmed.
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Affiliation(s)
- Rita Pavasini
- Centro Cardiologico Universitario, University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy.
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Via Olgettina Milano, 58-60, 20132 Milan, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Catholic University, Largo Francesco Vito, 1, 00168 Rome, Italy
| | - Nicolas Danchin
- Cardiology, European Hospital Georges-Pompidiou, 20 Rue Leblanc, 75015 Paris, France
| | - Kim Fox
- National Heart and Lung Institute, Imperial College and Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, Sydney Street, London SW36NP, UK
| | - Athanasios J Manolis
- Department of Cardiology, Asklepeion General Hospital, 1, Vas. Pavlou Street, 16673 Voula, Athens, Greece
| | - Mario Marzilli
- Cardiothoracic Department, Lungarno Antonio Pacinotti, 43, 56126 Pisa, Italy; Nottola Cardiology Division, Località Nottola, 53045, Ospedali Riuniti Valdichiana Sudest, Siena, Italy
| | - Giuseppe M C Rosano
- Clinical Academic Group, St George's Hospitals NHS Trust, Blackshaw Road, London SW17 0QT, UK; Department of Medical Sciences, IRCCS San Raffaele, Via della Pisana, 235, 00163 Rome, Italy
| | - José L Lopez-Sendon
- Cardiology Department, Hospital Universitario La Paz, IdiPaz, Paseo de la Castellana 261, Madrid 28036, Spain
| | - Fausto Pinto
- Hospital Universitário de Santa Maria/Centro Hospitalar Lisboa Norte, Centro Académico de Medicina de Lisboa, Centro Cardiovascular da Universidade de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Cristina Balla
- Centro Cardiologico Universitario, University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy
| | - Roberto Ferrari
- Centro Cardiologico Universitario, University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy; Maria Cecilia Hospital, GVM Care & Research, Via Corriera 1, Cotignola, RA, Italy
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Anti-Anginal Effectiveness and Tolerability of Trimetazidine Modified Release 80 Mg Once Daily in Stable Angina Patients in Real-World Practice. Adv Ther 2018; 35:1368-1377. [PMID: 30105656 PMCID: PMC6133142 DOI: 10.1007/s12325-018-0756-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Indexed: 12/19/2022]
Abstract
Introduction Trimetazidine (TMZ) was shown to reduce angina symptoms and increase the exercise capacity in stable angina (SA) patients. A new formulation allowing a once-daily (od) dosage could improve patients’ satisfaction and adherence. Methods ODA was a 3-month, observational, multicenter, prospective Russian study
in SA patients with persistent symptoms despite therapy. Angina attack frequency, short-acting nitrate (SAN) consumption, adherence to antianginal medications, and overall efficacy and tolerability of TMZ 80 mg od were assessed in a real-world setting. Results A total of 3066 patients were included (mean age 62.8, 48% male). After 3 months, TMZ 80 mg od treatment led to a significant (p < 0.001) decrease in angina attack frequency (from 4.7 ± 3.5 to 0.9 ± 1.3/week) and SAN use (from 4.5 ± 3.9 to 0.7 ± 1.3/week). Overall tolerability and effectiveness were rated as “very good” by the majority of physicians. Medication adherence improved significantly, with good adherence reported by 56% of patients (vs. 24% at baseline, p < 0.0001) and non-adherence by 3% (vs. 36% at baseline, p < 0.0001) at month 3. Patient satisfaction with TMZ od was 9.5 [on a scale of 1 to 10 (very satisfied)]. Patients reported improved physical activity: more patients reported no limitations (15% vs. 1% at baseline p < 0.01), slight limitation (46% vs. 5% at baseline, p < 0.001) or moderate limitation (30% vs. 23%, p < 0.01) and fewer patients reported substantial limitation (8% vs. 52% at baseline, p < 0.001) or very marked reduction (1% vs. 19% at baseline, p < 0.01) at month 3. Conclusion In this prospective, observational study, TMZ 80 mg od effectively reduced angina attacks and SAN consumption, improved physical activity and adherence and was well tolerated in chronic SA patients. Trial Registration ISRCTN registry Identifier, ISRCTN97780949. Funding Servier. Plain Language Summary Plain language summary available for this article.
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Birkenfeld AL, Jordan J, Dworak M, Merkel T, Burnstock G. Myocardial metabolism in heart failure: Purinergic signalling and other metabolic concepts. Pharmacol Ther 2018; 194:132-144. [PMID: 30149104 DOI: 10.1016/j.pharmthera.2018.08.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Despite significant therapeutic advances in heart failure (HF) therapy, the morbidity and mortality associated with this disease remains unacceptably high. The concept of metabolic dysfunction as an important underlying mechanism in HF is well established. Cardiac function is inextricably linked to metabolism, with dysregulation of cardiac metabolism pathways implicated in a range of cardiac complications, including HF. Modulation of cardiac metabolism has therefore become an attractive clinical target. Cardiac metabolism is based on the integration of adenosine triphosphate (ATP) production and utilization pathways. ATP itself impacts the heart not only by providing energy, but also represents a central element in the purinergic signaling pathway, which has received considerable attention in recent years. Furthermore, novel drugs that have received interest in HF include angiotensin receptor blocker-neprilysin inhibitor (ARNi) and sodium glucose cotransporter 2 (SGLT-2) inhibitors, whose favorable cardiovascular profile has been at least partly attributed to their effects on metabolism. This review, describes the major metabolic pathways and concepts of the healthy heart (including fatty acid oxidation, glycolysis, Krebs cycle, Randle cycle, and purinergic signaling) and their dysregulation in the progression to HF (including ketone and amino acid metabolism). The cardiac implications of HF comorbidities, including metabolic syndrome, diabetes mellitus and cachexia are also discussed. Finally, the impact of current HF and diabetes therapies on cardiac metabolism pathways and the relevance of this knowledge for current clinical practice is discussed. Targeting cardiac metabolism may have utility for the future treatment of patients with HF, complementing current approaches.
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Affiliation(s)
- Andreas L Birkenfeld
- Medical Clinic III, Universitätsklinikum "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany; Paul Langerhans Institute Dresden, Helmholtz Center Munich, University Hospital, Faculty of Medicine, Dresden, German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany; Division of Diabetes and Nutritional Sciences, Rayne Institute, King's College London, London, UK
| | - Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center and Chair of Aerospace Medicine, University of Cologne, Cologne, Germany
| | | | | | - Geoffrey Burnstock
- Autonomic Neuroscience Centre, Royal Free Campus, University College Medical School, London, UK; Department of Pharmacology and Therapeutics, The University of Melbourne, Parkville, Victoria, Australia.
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16
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Stable Angina Pectoris. Coron Artery Dis 2018. [DOI: 10.1016/b978-0-12-811908-2.00011-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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17
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Ferrari R, Camici PG, Crea F, Danchin N, Fox K, Maggioni AP, Manolis AJ, Marzilli M, Rosano GMC, Lopez-Sendon JL. A 'diamond' approach to personalized treatment of angina. Nat Rev Cardiol 2017; 15:120-132. [DOI: 10.1038/nrcardio.2017.131] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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18
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Dalal JJ, Mishra S. Modulation of myocardial energetics: An important category of agents in the multimodal treatment of coronary artery disease and heart failure. Indian Heart J 2017. [PMID: 28648439 PMCID: PMC5485408 DOI: 10.1016/j.ihj.2017.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
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.
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Affiliation(s)
| | - Sundeep Mishra
- Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
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19
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Real-world Evidence for the Antianginal Efficacy of Trimetazidine from the Russian Observational CHOICE-2 Study. Adv Ther 2017; 34:915-924. [PMID: 28220388 DOI: 10.1007/s12325-017-0490-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The guidelines recommend a beta-blocker or calcium channel blocker as the first-line medication for angina, supplemented by other agents for additional symptoms. One such agent is trimetazidine (TMZ), which has been shown to reduce the frequency of anginal episodes and improve exercise performance without affecting haemodynamic parameters. However, extensive real-world evidence for its efficacy in combination with first-line therapies has been lacking. METHODS The aim of this large-scale, Russian, multicentre, 6-month, open-label, prospective observational study was to assess the effect of adding TMZ modified release 35 mg bid to background antianginal therapy in the real-world clinical setting. RESULTS The study included 896 patients: 54% women, aged 29-90 years (42.6% >65 years), 63% with class II angina, and receiving beta-blockers alone or in combination (93%). Add-on TMZ reduced angina frequency and short-acting nitrate use within 2 weeks (both p < 0.0001) regardless of background therapy and maintained this effect over 6 months. It increased the proportion of patients with class I angina sixfold while decreasing that of class 3 angina almost fourfold. It also improved walking distance and well-being at 6 months (both p < 0.0001). Treatment was well tolerated. CONCLUSION Add-on TMZ is a safe and rapidly effective treatment for reducing angina attacks and nitrate use in the real-world clinical setting. It also increases exercise capacity and well-being. These effects are observed within 2 weeks and persist for at least 6 months.
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20
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Abstract
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.
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Affiliation(s)
- Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Rudolf Pizarro
- Hospital Italiano de Buenos AiresCardiac ServicesGascón 450Buenos AiresArgentina
| | - Jeff Harrison
- Faculty of Medical and Health SciencesSchool of PharmacyBuidling 50485 Park RoadGraftonAucklandNew Zealand
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21
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Abstract
All of the following traditional agents for the management of stable angina pectoris include the symptomatic treatment with heart rate–lowering agents such as β-blockers or non-dihydropyridine Ca-channel blockers, or ivabradine—the first selective sinus node If channel inhibitor—vasodilatators and preventive use of angiotensin-converting enzyme inhibitors affect the parameters of circulation directly. Trimetazidine exerts its anti-ischemic action by modulating cardiac metabolism without altering the hemodynamic functions, therefore represents an excellent complementary potential to the conventional angina treatment. It has a beneficial effect on the inflammatory profile and endothelial function and shows diverse benefits by reducing the number and the intensity of angina attacks and improving the clinical signs and symptoms of myocardial ischemia given as monotherapy as well as combined with other antianginal agents. Patients undergoing coronary revascularization procedures or with comorbid left ventricular dysfunction and diabetes mellitus also benefit from the protective effects of trimetazidine.
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Mishra S, Ray S, Dalal JJ, Sawhney JPS, Ramakrishnan S, Nair T, Iyengar SS, Bahl VK. Management standards for stable coronary artery disease in India. Indian Heart J 2016; 68 Suppl 3:S31-S49. [PMID: 28038722 PMCID: PMC5198886 DOI: 10.1016/j.ihj.2016.11.320] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Coronary artery disease (CAD) is one of the important causes of cardiovascular morbidity and mortality globally, giving rise to more than 7 million deaths annually. An increasing burden of CAD in India is a major cause of concern with angina being the leading manifestation. Stable coronary artery disease (SCAD) is characterised by episodes of transient central chest pain (angina pectoris), often triggered by exercise, emotion or other forms of stress, generally triggered by a reversible mismatch between myocardial oxygen demand and supply resulting in myocardial ischemia or hypoxia. A stabilised, frequently asymptomatic phase following an acute coronary syndrome (ACS) is also classified as SCAD. This definition of SCAD also encompasses vasospastic and microvascular angina under the common umbrella.
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Affiliation(s)
- Sundeep Mishra
- Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
| | | | | | - J P S Sawhney
- Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - S Ramakrishnan
- Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | | | | | - V K Bahl
- Department of Cardiology, AIIMS, New Delhi, India
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Manolis AJ, Poulimenos LE, Ambrosio G, Kallistratos MS, Lopez-Sendon J, Dechend R, Mancia G, Camm AJ. Medical treatment of stable angina: A tailored therapeutic approach. Int J Cardiol 2016; 220:445-53. [DOI: 10.1016/j.ijcard.2016.06.150] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/18/2016] [Accepted: 06/24/2016] [Indexed: 01/17/2023]
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Lopaschuk GD, Marzilli M. Mode of Action of Trimetazidine and Other New Metabolic Agents in the Treatment of Ischemic Heart Disease. Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1177/108925320300700116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- G. D. Lopaschuk
- Cardiovascular Research Group, University of Alberta, Edmonton, Canada; 423 Heritage Medical Research Center, University of Alberta, Edmonton, Alberta T6G 2S2, Canada
| | - M. Marzilli
- Cattedra di Malattie Cardiovascolari, University di Siena, Italy
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Ambrosio G, Mugelli A, Lopez-Sendón J, Tamargo J, Camm J. Management of stable angina: A commentary on the European Society of Cardiology guidelines. Eur J Prev Cardiol 2016; 23:1401-12. [DOI: 10.1177/2047487316648475] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 04/18/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Giuseppe Ambrosio
- Division of Cardiology, University of Perugia School of Medicine, Italy
| | - Alessandro Mugelli
- Department of Neuroscience, Drug Research and Child Health, University of Firenze, Italy
| | | | - Juan Tamargo
- Department of Pharmacology, Universidad Complutense, Spain
| | - John Camm
- St George's University of London and Imperial College London, UK
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Khouri C, Jouve T, Blaise S, Carpentier P, Cracowski JL, Roustit M. Peripheral vasoconstriction induced by β-adrenoceptor blockers: a systematic review and a network meta-analysis. Br J Clin Pharmacol 2016; 82:549-60. [PMID: 27085011 DOI: 10.1111/bcp.12980] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 04/01/2016] [Accepted: 04/14/2016] [Indexed: 12/31/2022] Open
Abstract
AIM Peripheral vasoconstriction has long been described as a vascular adverse effect of β-adrenoceptor blockers. Whether β-adrenoceptor blockers should be avoided in patients with peripheral vascular disease depends on pharmacological properties (e.g. preferential binding to β1 -adrenoreceptors or intrinsic sympathomimetic activity). However, this has not been confirmed in experimental studies. We performed a network meta-analysis in order to assess the comparative risk of peripheral vasoconstriction of different β-adrenoceptor blockers. METHOD We searched for randomized controlled trials (RCTs) including β-adrenoceptor blockers that were published in core clinical journals in the Pubmed database. All RCTs reporting peripheral vasoconstriction as an adverse effect of β-adrenoceptor blockers and controls were included. Sensitivity analyses were conducted including possibly confounding covariates (latitude, properties of the β-adrenoceptor blockers, e.g. intrinsic sympathomimetic activity, vasodilation, drug indication, drug doses). The protocol and the detailed search strategy are available online (PROSPERO registry CRD42014014374). RESULTS Among 2238 records screened, 38 studies including 57 026 patients were selected. Overall, peripheral vasoconstriction was reported in 7% of patients with β-adrenoceptor blockers and 4.6% in the control groups (P < 0.001), with heterogeneity among drugs. Atenolol and propranolol had a significantly higher risk than placebo, whereas pindolol, acebutolol and oxprenolol had not. CONCLUSION Our results suggest that β-adrenoceptor blockers have variable propensity to enhance peripheral vasoconstriction and that it is not related to preferential binding to β1 -adrenoceptors. These findings challenge FDA and European recommendations regarding precautions and contra-indications of use of β-adrenoceptor blockers and suggest that β-adrenoceptor blockers with intrinsic sympathomimetic activity could be safely used in patients with peripheral vascular disease.
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Affiliation(s)
- Charles Khouri
- Pôle Santé Publique Pharmacovigilance, Grenoble University Hospital (CHU Grenoble-Alpes), F-38000, Grenoble, France
| | - Thomas Jouve
- Pôle Recherche, Pharmacologie Clinique, INSERM CIC1406, Grenoble University Hospital (CHU Grenoble-Alpes), F-38000, Grenoble, France
| | - Sophie Blaise
- Univ. Grenoble Alpes HP2, F-38000, Grenoble, France.,INSERM, HP2, F-38000, Grenoble, France.,Grenoble University Hospital (CHU Grenoble-Alpes), Clinique de Médecine Vasculaire, F-38000, Grenoble, France
| | - Patrick Carpentier
- Grenoble University Hospital (CHU Grenoble-Alpes), Clinique de Médecine Vasculaire, F-38000, Grenoble, France
| | - Jean-Luc Cracowski
- Pôle Recherche, Pharmacologie Clinique, INSERM CIC1406, Grenoble University Hospital (CHU Grenoble-Alpes), F-38000, Grenoble, France.,Univ. Grenoble Alpes HP2, F-38000, Grenoble, France.,INSERM, HP2, F-38000, Grenoble, France
| | - Matthieu Roustit
- Pôle Recherche, Pharmacologie Clinique, INSERM CIC1406, Grenoble University Hospital (CHU Grenoble-Alpes), F-38000, Grenoble, France.,Univ. Grenoble Alpes HP2, F-38000, Grenoble, France.,INSERM, HP2, F-38000, Grenoble, France
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Ambrosio G, Tamargo J, Grant PJ. Non-haemodynamic anti-anginal agents in the management of patients with stable coronary artery disease and diabetes: A review of the evidence. Diab Vasc Dis Res 2016; 13:98-112. [PMID: 26873904 DOI: 10.1177/1479164115609028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Patients with coronary artery disease and concomitant diabetes mellitus tend to have more extensive vessel disease than non-diabetes mellitus coronary artery disease patients, are at high risk of adverse cardiovascular events and suffer from a great anginal burden. Very few trials have specifically addressed the issue of optimal anti-anginal therapy in coronary artery disease patients who also have diabetes mellitus. Among 'classical' anti-anginal agents, recent guidelines do not specifically recommend any molecule over others; however, European Society of Cardiology guidelines acknowledge that favourable data in patients with concomitant diabetes mellitus and coronary artery disease are available for trimetazidine and ranolazine, two anti-anginal agents with a non-haemodynamic mechanism of action. The aim of this article is to review available evidence supporting the anti-anginal efficacy of these two drugs in the difficult-to-treat population of diabetes mellitus patients, including their effects on glycated haemoglobin (HbA1c), a measure of medium-term glycaemic control. Although direct head-to-head comparisons have not been performed, available evidence favours ranolazine as an effective anti-anginal agent over trimetazidine in this population. In addition, ranolazine lowers HbA1c, indicating that it may improve glycaemic control in patients with diabetes mellitus. Conversely, scanty data are available on the metabolic effects of trimetazidine in this cohort of patients. Thus, ranolazine may represent a valuable therapeutic option in stable coronary artery disease patients with diabetes mellitus.
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Affiliation(s)
- Giuseppe Ambrosio
- Division of Cardiology, School of Medicine, University of Perugia, Perugia, Italy
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Peter J Grant
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Milinković I, Rosano G, Lopatin Y, Seferović PM. The Role of Ivabradine and Trimetazidine in the New ESC HF Guidelines. Card Fail Rev 2016; 2:123-129. [PMID: 28785466 DOI: 10.15420/cfr.2016:13:1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Ivan Milinković
- Department of Cardiology,Clinical Centre of Serbia, Belgrade, Serbia
| | - Giuseppe Rosano
- IRCCS San Raffaele,Rome, Italy.,Cardiovascular and Cell Sciences Institute,St George's University of London, London, UK
| | - Yuri Lopatin
- Volgograd Medical University,Cardiology Centre, Volgograd, Russia
| | - Petar M Seferović
- Department of Cardiology,Clinical Centre of Serbia, Belgrade, Serbia
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Pradhan A. Metabolic management of heart disease. JOURNAL OF THE PRACTICE OF CARDIOVASCULAR SCIENCES 2016. [DOI: 10.4103/jpcs.jpcs_92_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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McCarthy CP, Mullins KV, Kerins DM. The role of trimetazidine in cardiovascular disease: beyond an anti-anginal agent. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 2:266-72. [DOI: 10.1093/ehjcvp/pvv051] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 11/30/2015] [Indexed: 12/19/2022]
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Abstract
Chronic angina is a common manifestation of ischaemic heart disease. Medical treatments are the mainstay approach to reduce the occurrence of angina and improve patients' quality of life. This Series paper focuses on commonly used standard treatments (eg, nitrates, β blockers, and calcium-channel blockers), emerging anti-angina treatments (which are not available in all parts of the world), and experimental treatments. Although many emerging treatments are available, evidence is scarce about their ability to reduce angina and ischaemia.
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Affiliation(s)
- Steen E Husted
- Department of Medicine, Hospital Unit West, Herning, Denmark; Department of Clinical Pharmacology, Institute of Biomedicine, Aarhus University, Aarhus, Denmark
| | - E Magnus Ohman
- The Program for Advanced Coronary Disease, Division of Cardiology, Duke University and Duke Clinical Research Institute, Durham, NC, USA.
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Sandhiya S, Dkhar SA, Pillai AA, George M, Jayaraman B, Chandrasekaran A. Comparison of ranolazine and trimetazidine on glycemic status in diabetic patients with coronary artery disease - a randomized controlled trial. J Clin Diagn Res 2015; 9:OC01-5. [PMID: 25738014 DOI: 10.7860/jcdr/2015/10594.5448] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 10/31/2014] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Cardiovascular diseases have become the leading cause of death around the globe and diabetes mellitus (DM) is considered to be a coronary artery disease (CAD) risk equivalent. Ranolazine, an anti anginal drug has been found to reduce Glycated haemoglobin (HbA1c) in diabetes patients with chronic angina. However the effect of another antianginal drug trimetazidine, on glycemic status is not clear. AIM To compare the effect of ranolazine and trimetazidine on glycemic status in diabetic patients with CAD. SETTINGS AND DESIGN Patients diagnosed with CAD and diabetes mellitus attending Cardiology Out Patient Department (OPD), Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India were recruited for this randomized open label parallel arm trial. MATERIALS AND METHODS The study conducted from January-2012 to April-2013 had 47 eligible patients diagnosed with CAD and diabetes mellitus. They were randomized to receive either ranolazine 500 mg BD or trimetazidine 35 mg BD for 12 weeks. HbA1c levels, fasting blood glucose (FBG), lipid profile, QT and QTc intervals were measured at baseline and after 12 weeks. STATISTICAL ANALYSIS Unpaired t-test was used to compare the baseline characteristics of between the groups while comparison within the groups were done using Paired t-test. Wilcoxon and Mann Whitney U-tests were used for non parametric data. Graph pad instat version-3 was used for statistical analysis. Values were expressed as mean ± SD. A p < 0.05 was considered statistically significant. RESULTS The study could not find any change in HbA1c levels in both ranolazine and trimetazidine groups. The adverse effects reported from patients on ranolazine include angina, constipation, postural hypotension, headache, dizziness, nausea and weakness while patients on trimetazidine complained of constipation, weakness, palpitations, angina, dizziness, nausea, dyspepsia, headache, gastric discomfort, joint pain, etc. CONCLUSION In patients with chronic angina and diabetes mellitus Ranolazine 500mg BD and Trimetazidine 35mg BD did not show any effect on HbA1c and fasting blood glucose lebel.
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Affiliation(s)
- Selvarajan Sandhiya
- Assistant Professor, Department of Clinical Pharmacology, JIPMER , Puducherry, India
| | | | | | - Melvin George
- Assistant Professor, Cardiac Clinical Trials, Department of Cardiology, SRM Medical College Hospital & Research Centre , Kattankulathur, Chennai, India
| | | | - Adithan Chandrasekaran
- Senior Professor & Head, Department of Clinical Pharmacology, JIPMER , Puducherry, India
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Tsioufis K, Andrikopoulos G, Manolis A. Trimetazidine and cardioprotection: facts and perspectives. Angiology 2014; 66:204-10. [PMID: 24719262 DOI: 10.1177/0003319714530040] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Helmy SA, Mansour NO. In vitro dissolution and in vivo bioequivalence evaluation of two brands of trimetazidine tablets. Clin Pharmacol Drug Dev 2014; 3:139-43. [PMID: 27128458 DOI: 10.1002/cpdd.63] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 08/21/2013] [Indexed: 11/09/2022]
Abstract
Trimetazidine is an effective anti-anginal agent and anti-ischaemic effect. The objective of this study was to assess the in vitro dissolution and to evaluate the bioavailability of two brands of trimetazidine dihydrochloride tablets. Prior to the in vivo PKs study, an in vitro comparative dissolution test was performed for 2 oral brands of trimetazidine dihydrochloride tablets (20 mg). In vivo PKs study was evaluated in 24 healthy male volunteers after a single dose oral administration in an open, randomized, two-way crossover study with a washout period of 1 week. After an overnight fast, human volunteers were randomly allocated to receive a single dose of either test or reference product. Blood samples were collected over a 24-hour period following drug administration and plasma was analyzed for trimetazidine concentrations using a validated high-performance liquid chromatography assay method. The PK parameters Cmax , AUC0-t , AUC0-∞ , tmax , and t1/2 were determined from plasma concentration-time profiles. The 90% confidence intervals for the ratio of log transformed values of Cmax , AUC0-t , and AUCt-∞ of the test product over those of reference were within the acceptable range (0.8-1.25) for bioequivalence. As a result, the 2 trimetazidine formulations are considered bioequivalent and thus could be prescribed interchangeably in the medical practice based on its PK effect and biopharmaceutical performance.
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Affiliation(s)
- Sally A Helmy
- Department of Pharmaceutics, Faculty of Pharmacy, Damanhour University, Damanhour, Egypt
| | - Noha O Mansour
- Bioavailability Unit, Faculty of Pharmacy, Tanta University, Tanta, Egypt
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Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, Bugiardini R, Crea F, Cuisset T, Di Mario C, Ferreira JR, Gersh BJ, Gitt AK, Hulot JS, Marx N, Opie LH, Pfisterer M, Prescott E, Ruschitzka F, Sabaté M, Senior R, Paul Taggart D, van der Wall EE, Vrints CJ, Luis Zamorano J, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Anton Sirnes P, Luis Tamargo J, Tendera M, Torbicki A, Wijns W, Windecker S, Knuuti J, Valgimigli M, Bueno H, Claeys MJ, Donner-Banzhoff N, Erol C, Frank H, Funck-Brentano C, Gaemperli O, González-Juanatey JR, Hamilos M, Hasdai D, Husted S, James SK, Kervinen K, Kolh P, Dalby Kristensen S, Lancellotti P, Pietro Maggioni A, Piepoli MF, Pries AR, Romeo F, Rydén L, Simoons ML, Anton Sirnes P, Gabriel Steg P, Timmis A, Wijns W, Windecker S, Yildirir A, Luis Zamorano J. Guía de Práctica Clínica de la ESC 2013 sobre diagnóstico y tratamiento de la cardiopatía isquémica estable. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Wang W, Lopaschuk GD. Metabolic therapy for the treatment of ischemic heart disease: reality and expectations. Expert Rev Cardiovasc Ther 2014; 5:1123-34. [DOI: 10.1586/14779072.5.6.1123] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Novikova MV, Glezer MG. TRIMETAZIDINE MR EFFECTS ON THE PARAMETERS OF 24-HOUR ELECTROCARDIOGRAM MONITORING AND HEART RATE VARIABILITY. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2013. [DOI: 10.15829/1728-8800-2013-5-68-74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Aim. To assess the effects of the four-month trimetazidine MR therapy on the parameters of 24-hour electrocardiogram (ECG) monitoring and heart rate variability (HRV) in patients with stable coronary heart disease (CHD).Material and methods. This prospective, non-randomised study, with the inclusion of 66 consecutive patients who had stable CHD and stable stress test results, investigated the effects of trimetazidine MR therapy on the parameters of 24-hour ECG monitoring and HRV.Results. Trimetazidine MR did not markedly affect the 24-hour, daytime, or nighttime levels of heart rate. Trimetazidine MR therapy was not associated with any substantial changes in frequency and time-domain HRV parameters or in the incidence of cardiac arrhythmias. However, there was a significant reduction in the number of patients with ST segment depression (from 66,7% to 43,8%; p<0,001) and in the duration of ischemic episodes (from 10 (6,2;21) minutes to 7,42 (5;12,3) minutes (p=0,025)).Conclusion. Adding trimetazidine MR to the treatment of patients with stable CHD provides an additional beneficial antiischemic effect.
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Affiliation(s)
- M. V. Novikova
- Moscow City Healthcare Department, City Clinical Hospital No. 59
| | - M. G. Glezer
- Moscow City Healthcare Department, City Clinical Hospital No. 59;
I.M. Sechenov First Moscow State Medical University, Moscow
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Vitale C, Spoletini I, Malorni W, Perrone-Filardi P, Volterrani M, Rosano GM. Efficacy of trimetazidine on functional capacity in symptomatic patients with stable exertional angina — The VASCO-angina study. Int J Cardiol 2013. [DOI: 10.1016/j.ijcard.2012.11.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, Bugiardini R, Crea F, Cuisset T, Di Mario C, Ferreira JR, Gersh BJ, Gitt AK, Hulot JS, Marx N, Opie LH, Pfisterer M, Prescott E, Ruschitzka F, Sabaté M, Senior R, Taggart DP, van der Wall EE, Vrints CJM, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Knuuti J, Valgimigli M, Bueno H, Claeys MJ, Donner-Banzhoff N, Erol C, Frank H, Funck-Brentano C, Gaemperli O, Gonzalez-Juanatey JR, Hamilos M, Hasdai D, Husted S, James SK, Kervinen K, Kolh P, Kristensen SD, Lancellotti P, Maggioni AP, Piepoli MF, Pries AR, Romeo F, Rydén L, Simoons ML, Sirnes PA, Steg PG, Timmis A, Wijns W, Windecker S, Yildirir A, Zamorano JL. 2013 ESC guidelines on the management of stable coronary artery disease. Eur Heart J 2013; 34:2949-3003. [PMID: 23996286 DOI: 10.1093/eurheartj/eht296] [Citation(s) in RCA: 2900] [Impact Index Per Article: 263.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
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- The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines
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Kim JS, Kim CH, Chun KJ, Kim JH, Park YH, Kim J, Choi JH, Lee SH, Kim EJ, Yu DG, Ahn EY, Jeong MH. Effects of trimetazidine in patients with acute myocardial infarction: data from the Korean Acute Myocardial Infarction Registry. Clin Res Cardiol 2013; 102:915-22. [PMID: 23982468 DOI: 10.1007/s00392-013-0611-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 08/14/2013] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Jeong Su Kim
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, 626-770, Korea
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Effect of partial fatty acid oxidation inhibition with trimetazidine on mortality and morbidity in heart failure: Results from an international multicentre retrospective cohort study. Int J Cardiol 2013; 163:320-325. [DOI: 10.1016/j.ijcard.2012.09.123] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 09/19/2012] [Accepted: 09/22/2012] [Indexed: 11/20/2022]
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Dehina L, Vaillant F, Tabib A, Bui-Xuan B, Chevalier P, Dizerens N, Bui-Xuan C, Descotes J, Blanc-Guillemaud V, Lerond L, Timour Q. Trimetazidine demonstrated cardioprotective effects through mitochondrial pathway in a model of acute coronary ischemia. Naunyn Schmiedebergs Arch Pharmacol 2012; 386:205-15. [PMID: 23263451 DOI: 10.1007/s00210-012-0826-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 12/10/2012] [Indexed: 02/06/2023]
Abstract
Myocardial ischemia affects mitochondrial function leading to ionic imbalance and susceptibility to ventricular fibrillation. Trimetazidine (TMZ), a metabolic agent, is clinically used as an anti-anginal therapy. This study was conducted to compare the effect of TMZ 20 mg immediate release (IR) and TMZ 35 mg modified release (MR), two bioequivalent marketed formulations of TMZ, on cardioprotection during acute ischemia in pigs. A 4-day oral treatment with TMZ 20 mg IR (800 mg, tid) or TMZ 35 mg MR (1,400 mg, bid) had no effect on ventricular fibrillation threshold (VFT) prior to ischemia but significantly prevented the decrease in VFT observed in placebo-treated groups after a 1-min left anterior descending coronary artery occlusion. This effect occurred without modifying cardiac hemodynamic and conduction parameters. In both TMZ-treated groups, a significant reduction of the ischemic area as well as a protection of cardiomyocytes were observed. Cardiac enzymatic activity (phosphorylase, succinate dehydrogenase, ATPase) was increased in TMZ-treated groups. Both formulations preserved mitochondrial structure and improved mitochondrial function as demonstrated by a twofold increase of oxidative phosphorylation, by a reduction of reactive oxygen species (ROS) production (>30 %) and by a trend to increase the mitochondrial calcium retention capacity. In this model of ischemia, both TMZ formulations, leading to equivalent TMZ plasma exposures, demonstrated similar cardioprotective effects. This protection could be attributed to a preservation of mitochondrial structure and function, which plays a central role in ATP and ROS production and consequently could be considered as a target of cardioprotection.
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Affiliation(s)
- L Dehina
- EA4612 Neurocardiologie, Université Claude Bernard - Lyon1, 8 avenue Rockefeller, 69373, Lyon cedex 08, France
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Shu DF, Dong BR, Lin XF, Wu TX, Liu GJ. Long-term beta blockers for stable angina: systematic review and meta-analysis. Eur J Prev Cardiol 2011; 19:330-41. [PMID: 22779086 DOI: 10.1177/1741826711409325] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objectives: To assess the effects of long-term beta blockers in patients with stable angina. Methods: We reviewed the literature up to June 2010 from CENTRAL, MEDLINE, EMBASE, CBM, and CNKI for randomized controlled trials. The appropriate data were meta-analysed using Revman 5.0. Results: Twenty-six trials including 6108 patients were identified. The treatment with beta blockers has significantly decreased all-cause mortality when compared with no control (OR 0.40, 95% CI 0.20 to 0.79), but has had no statistically differences when compared with placebo (OR 0.92, 95% CI 0.62 to 1.38) and with calcium-channel blocker (CCB) (OR 0.84, 95% CI 0.49 to 1.44). This was similar in patients with fatal and non-fatal acute myocardial infarction when compared with placebo (OR 0.82, 95% CI 0.57 to 1.17) or CCB (OR 1.08, 95% CI 0.71 to 1.66); on revascularization and quality of life. The beta blockers reduced the incident of unstable angina compared to no treatment (OR 0.14, 95% CI 0.07 to 0.29), but increased unstable angina compared to placebo (OR 3.32, 95% CI 1.50 to 7.36). There was a significant reduction of nitrate consumption when beta blockers were compared with CCBs (OR −1.18, 95% CI −1.54 to −0.82), but not with placebo and trimetazidine. There was no significant difference in angina attack between each group. Side effects in beta blocker were similar with ones in controls. Conclusions: Beta blockers may decrease the death and unstable angina when compared with no treatment, but no more effective than other anti-anginal agents on prophylaxis of myocardial ischaemia in stable angina patients.
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Affiliation(s)
- De Fen Shu
- Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Bi Rong Dong
- Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Xiu Fang Lin
- Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Tai Xiang Wu
- Chinese Cochrane Centre, Chinese EBM Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Guan Jian Liu
- Chinese Cochrane Centre, Chinese EBM Centre, West China Hospital, Sichuan University, Chengdu, China
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Jaswal JS, Keung W, Wang W, Ussher JR, Lopaschuk GD. Targeting fatty acid and carbohydrate oxidation--a novel therapeutic intervention in the ischemic and failing heart. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2011; 1813:1333-50. [PMID: 21256164 DOI: 10.1016/j.bbamcr.2011.01.015] [Citation(s) in RCA: 266] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 12/16/2010] [Accepted: 01/11/2011] [Indexed: 12/19/2022]
Abstract
Cardiac ischemia and its consequences including heart failure, which itself has emerged as the leading cause of morbidity and mortality in developed countries are accompanied by complex alterations in myocardial energy substrate metabolism. In contrast to the normal heart, where fatty acid and glucose metabolism are tightly regulated, the dynamic relationship between fatty acid β-oxidation and glucose oxidation is perturbed in ischemic and ischemic-reperfused hearts, as well as in the failing heart. These metabolic alterations negatively impact both cardiac efficiency and function. Specifically there is an increased reliance on glycolysis during ischemia and fatty acid β-oxidation during reperfusion following ischemia as sources of adenosine triphosphate (ATP) production. Depending on the severity of heart failure, the contribution of overall myocardial oxidative metabolism (fatty acid β-oxidation and glucose oxidation) to adenosine triphosphate production can be depressed, while that of glycolysis can be increased. Nonetheless, the balance between fatty acid β-oxidation and glucose oxidation is amenable to pharmacological intervention at multiple levels of each metabolic pathway. This review will focus on the pathways of cardiac fatty acid and glucose metabolism, and the metabolic phenotypes of ischemic and ischemic/reperfused hearts, as well as the metabolic phenotype of the failing heart. Furthermore, as energy substrate metabolism has emerged as a novel therapeutic intervention in these cardiac pathologies, this review will describe the mechanistic bases and rationale for the use of pharmacological agents that modify energy substrate metabolism to improve cardiac function in the ischemic and failing heart. This article is part of a Special Issue entitled: Mitochondria and Cardioprotection.
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Affiliation(s)
- Jagdip S Jaswal
- Mazankowski Alberta Heart Institute, Departments of Pediatrics and Pharmacology, University of Alberta, Edmonton, Alberta, Canada
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Meenakshi R, Jagannathan L, Gunasekaran S, Srinivasan S. FT-IR, FT-Raman and UV–vis spectra and quantum chemical investigation of trimetazidine. MOLECULAR SIMULATION 2010. [DOI: 10.1080/08927022.2010.497925] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Improvement of mechanical heart function by trimetazidine in db/db mice. Acta Pharmacol Sin 2010; 31:560-9. [PMID: 20383170 DOI: 10.1038/aps.2010.31] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIM To investigate the influence of trimetazidine, which is known to be an antioxidant and modulator of metabolism, on cardiac function and the development of diabetic cardiomyopathy in db/db mouse. METHODS Trimetazidine was administered to db/db mice for eight weeks. Cardiac function was measured by inserting a Millar catheter into the left ventricle, and oxidative stress and AMP-activated protein kinase (AMPK) activity in the myocardium were evaluated. RESULTS Untreated db/db mice exhibited a significant decrease in cardiac function compared to normal C57 mice. Oxidative stress and lipid deposition were markedly increased in the myocardium, concomitant with inactivation of AMPK and increased expression of peroxisome proliferator-activated receptor coactivator-1 alpha (PGC-1 alpha). Trimetazidine significantly improved systolic and diastolic function in hearts of db/db mice and led to reduced production of reactive oxygen species and deposition of fatty acid in cardiomyocytes. Trimetazidine also caused AMPK activation and reduced PGC-1 alpha expression in the hearts of db/db mice. CONCLUSION The data suggest that trimetazidine significantly improves cardiac function in db/db mice by attenuating lipotoxicity and improving the oxidation status of the heart. Activation of AMPK and decreased expression of PGC-1 alpha were involved in this process. Furthermore, our study suggests that trimetazidine suppresses the development of diabetic cardiomyopathy, which warrants further clinical investigation.
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Mouquet F, Rousseau D, Domergue-Dupont V, Grynberg A, Liao R. Effects of trimetazidine, a partial inhibitor of fatty acid oxidation, on ventricular function and survival after myocardial infarction and reperfusion in the rat. Fundam Clin Pharmacol 2009; 24:469-76. [PMID: 20030737 DOI: 10.1111/j.1472-8206.2009.00802.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Trimetazidine (TMZ), a partial inhibitor of fatty acid oxidation, has been effective in treating chronic angina, but its effects on the development of post-myocardial infarction (MI) left ventricular remodeling are not defined. In this study, we tested whether chronic pre-MI administration of TMZ would be beneficial during and after acute MI. Two-hundred male Wistar rats were studied in four groups: sham + TMZ diet (n = 20), sham + control diet (n = 20), MI + TMZ diet (n = 80), and MI + control diet (n = 80) splitted into one short-term and one long-term experiments. Sham surgery consisted of a thoracotomy without coronary ligation. MI was induced by coronary occlusion followed by reperfusion. Left ventricle (LV) function and remodeling were assessed by serial echocardiography throughout a 24-week post-MI period. LV remodeling was also assessed by quantitative histological analysis of post-MI scar formation at 24 weeks post-MI. During the short-term experiment, 10/80 rats died after MI, with no difference between groups (MI + control = 7/40, MI + TMZ = 3/40, P = 0.3). In the long-term experiment, the deaths occurred irregularly over the 24 weeks with no difference between groups (MI + control = 16% mortality, MI + TMZ = 17%, P = 0.8). There was no difference between groups as regard to LV ejection fraction (MI + control = 36 +/- 13%, MI + TMZ = 35 +/- 13%, P = 0.6). In this experimental model, TMZ had no effects on the post-MI occurrence of LV dysfunction or remodeling. Further investigations are warranted to assess whether the partial inhibition of fatty acid oxidation may limit the ability of the heart to respond to acute severe stress.
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Affiliation(s)
- Frederic Mouquet
- The Cardiac Muscle Research Laboratory, Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA.
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Onay-Besikci A, Ozkan SA. Trimetazidine revisited: a comprehensive review of the pharmacological effects and analytical techniques for the determination of trimetazidine. Cardiovasc Ther 2008; 26:147-65. [PMID: 18485136 DOI: 10.1111/j.1527-3466.2008.00043.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- A Onay-Besikci
- Department of Pharmacology, Faculty of Pharmacy, Ankara University, Tandogan, Ankara, Turkey.
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Sui J, Zhang J, Ching CB, Chen WN. Comparative Proteomic Analysis of Extracellular Proteins Reveals Secretion of T-Kininogen from Vascular Smooth Muscle Cells in Response to Incubation with S-Enantiomer of Propranolol. Mol Pharm 2008; 5:885-90. [DOI: 10.1021/mp800012x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jianjun Sui
- School of Chemical and Biomedical Engineering, College of Engineering, Nanyang Technological University, 62 Nanyang Drive, Singapore 637459
| | - Jianhua Zhang
- School of Chemical and Biomedical Engineering, College of Engineering, Nanyang Technological University, 62 Nanyang Drive, Singapore 637459
| | - Chi Bun Ching
- School of Chemical and Biomedical Engineering, College of Engineering, Nanyang Technological University, 62 Nanyang Drive, Singapore 637459
| | - Wei Ning Chen
- School of Chemical and Biomedical Engineering, College of Engineering, Nanyang Technological University, 62 Nanyang Drive, Singapore 637459
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Vaillant F, Tsibiribi P, Bricca G, Bui-Xuan B, Bescond-Jacquet A, Tabib A, Descotes J, Timour Q. Trimetazidine protective effect against ischemia-induced susceptibility to ventricular fibrillation in pigs. Cardiovasc Drugs Ther 2007; 22:29-36. [PMID: 18157622 DOI: 10.1007/s10557-007-6076-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2006] [Accepted: 12/06/2007] [Indexed: 11/25/2022]
Abstract
PURPOSE Ventricular fibrillation (VF) is a possible consequence of brief myocardial ischemia. Such a short ischemia does not provoke cell damage, but induces changes in intracellular cardiac metabolism due to diminished oxygen supply to the heart. Trimetazidine (TMZ) is a drug able to restore the metabolic balance between fatty acid and glucose oxidation in ischemic myocardial cells. The aim of this double-blind study was to investigate TMZ effect on VF in pigs during short-term ischemia. METHODS Ischemia was induced after thoracotomy by complete, but brief (1 min) occlusion of the left anterior descending coronary artery under electrical stimulation. The ventricular fibrillation threshold (VFT), heart rate (HR), various hemodynamic parameters and malondialdehyde (MDA) blood levels were measured before and during ischemia in two groups of eight anesthetized pigs. The mass of ischemic myocardial tissue was also evaluated. RESULTS No effects on either the HR or the hemodynamic parameters were observed during myocardial ischemia, whereas TMZ increased the VFT and decreased both MDA blood levels (an index of lipid peroxidation) and the ischemic area. CONCLUSIONS TMZ limited ischemia-induced electrical dysfunction leading to cardiac susceptibility to VF by decreasing lipid peroxidation and maintaining ionic homeostasis. TMZ could therefore provide protection against ischemia-induced VF.
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Affiliation(s)
- Fanny Vaillant
- Laboratoire de Pharmacologie Médicale, Faculté de Médecine Grange-Blanche, INSERM ERI 22, Université Claude Bernard Lyon-I, 8 avenue Rockefeller, 69373, Lyon cedex 08, France
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