Efficacy of trimetazidine in patients with recurrent angina: a subgroup analysis of the TRIMPOL II study

ACPTI study: Being positive in a negative situation is not naivety - Trimetazidine still has role in symptomatic CAD patients

RESULTS

of the efficAcy and safety of Trimetazidine in patients with angina pectoris having been treated by Percutaneous Coronary Intervention (ATPCI) study showed no significant difference in the incidence of primary endpoint events between trimetazidine and placebo group in angina patients who recently underwent percutaneous coronary intervention. However, the study had limitations specific to both, design and selection of patient population. Here, we present some explanations for the null effects of trimetazidine in the ATPCI study and their relevance in routine clinical practice.

Trimetazidine and Bisoprolol to Treat Angina in Symptomatic Patients: Post Hoc Analysis From the CHOICE-2 Study

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

Role of endothelial dysfunction in determining angina after percutaneous coronary intervention: Learning from pathophysiology to optimize treatment

Endothelial dysfunction (EnD) is a hallmark feature of coronary artery disease (CAD), representing the key early step of atherosclerotic plaque development and progression. Percutaneous coronary intervention (PCI) is performed daily worldwide to treat symptomatic CAD, however a consistent proportion of patients remain symptomatic for angina despite otherwise successful revascularization. EnD plays a central role in the mechanisms of post-PCI angina, as it is strictly associated with both structural and functional abnormalities in the coronary arteries that may persist, or even accentuate, following PCI. The assessment of endothelial function in patients undergoing PCI might help to identify those patients at higher risk of future cardiovascular events and recurrent/persistent angina who might therefore benefit more from an intensive treatment. In this review, we address the role of EnD in determining angina after PCI, discussing its pathophysiological mechanisms, diagnostic approaches and therapeutic perspectives.

A randomized, double-blind, placebo-controlled trial to assess the efficAcy and safety of Trimetazidine in patients with angina pectoris having been treated by percutaneous coronary intervention (ATPCI study): Rationale, design, and baseline characteristics

BACKGROUND

About 30% of angina patients have persisting symptoms despite successful revascularization and antianginal therapy. Moreover, in stable patients, percutaneous coronary intervention (PCI) does not improve survival as compared with medical therapy alone. Trimetazidine, an antianginal agent devoid of hemodynamic effect, may help reducing symptoms and improving outcomes after PCI. The ATPCI study is investigating the efficacy and safety of adding trimetazidine to standard-of-care in angina patients who had a recent PCI.

METHODS

ATPCI is a randomized, double-blind, parallel-group, placebo-controlled, event-driven study in patients with coronary artery disease having undergone PCI because of stable angina (elective PCI) or unstable angina/NSTEMI (urgent PCI). After PCI, patients were randomized to trimetazidine (35 mg bid) or placebo on top of standard-of-care including event prevention drugs and antianginal treatment. Patients will be followed for 2 to 4 years. The primary efficacy endpoint is a composite of cardiac death, hospitalization for a cardiac event and recurrence or persistence of angina. Safety events related to trimetazidine use will be monitored.

RESULTS

Recruitment lasted from September 2014 to June 2016. A total of 6007 patients were enrolled (58% and 42% after elective and urgent PCI, respectively). Mean age was 61 years, 77% were males, and median durations of coronary artery disease were 1 and 5 months (if urgent or elective PCI, respectively). Almost all patients received drugs for event prevention and antianginal therapy at baseline.

CONCLUSION

The ATPCI study will shed further light on the management of contemporary angina patients after PCI. Results are expected in 2019.

Trimetazidine in Practice: Review of the Clinical and Experimental Evidence

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 I_f 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.

Trimetazidine and cardioprotection: facts and perspectives

Trimetazidine (TMZ) is a metabolic agent used in cardiology for more than 40 years. Several studies assessed the cardioprotective effects of TMZ in patients with chronic coronary heart disease (CHD) as well as in patients with heart failure (HF). In light of the inclusion of TMZ in the current guidelines on the management of stable CHD, we reviewed the published literature on TMZ, focusing mainly its effects on patients with stable angina and HF. According to the published literature, there is sufficient evidence to support the addition of this agent in the treatment of symptomatic patients with stable angina.

Effects of trimetazidine in nonischemic heart failure: a randomized study

OBJECTIVES

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

METHODS AND RESULTS

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

CONCLUSIONS

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

The Impact of Trimetazidine Treatment on Left Ventricular Functions and Plasma Brain Natriuretic Peptide Levels in Patients with Non-ST Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Background and Objectives

The aim of this study was to investigate the impact of treatment with oral trimetazidine (TMZ) applied before and after percutaneous coronary interventions (PCI) on short-term left ventricular functions and plasma brain natriuretic peptide (BNP) levels in patients with non-ST segment elevation myocardial infarction (NSTEMI) undergoing PCI.

Subjects and Methods

The study included 45 patients who were undergoing PCI with the diagnosis of NSTEMI. The patients were randomized into two groups. The first group (n=22) of the patients hospitalized with the diagnosis of NSTEMI was given conventional therapy plus 60 mg TMZ just prior to PCI. Treatment with TMZ was continued for one month after the procedure. TMZ treatment was not given to the second group (n=23). Echocardiography images were recorded and plasma BNP levels were measured just prior to the PCI and on the 1st and 30th days after PCI.

Results

The myocardial performance index (MPI) was greater in the second group (p=0.02). In the comparison of BNP levels, they significantly decreased in both of the groups during the 30-day follow-up period (29.0±8 and 50.6±33, p<0.01 respectively). However, decreasing of BNP levels was higher in the group administered with TMZ. The decrease of left ventriclular end-diastolic volume was observed in all groups at 30 days after intervention, but was higher in the group administered with TMZ (p=0.01).

Conclusion

Trimetazidine treatment commencing prior to PCI and continued after PCI in patients with NSTEMI provides improvements in MPI, left ventricular end diastolic volume and a decrease in BNP levels.

Recurrent angina after coronary angioplasty: mechanisms, diagnostic and therapeutic options

Recurrent angina in patients who underwent percutaneous coronary intervention is defined as recurrence of chest pain or chest discomfort. Careful assessment is recommended to differentiate between non-cardiac and cardiac causes. In the case of the latter, recurrent angina occurrence can be related to structural ('stretch pain', in-stent restenosis, in-stent thrombosis, incomplete revascularization, progression of coronary atherosclerosis) or functional (coronary micro-vascular dysfunction, epicardial coronary spasm) causes. Even though a complete diagnostic algorithm has not been validated, ECG exercise testing, stress imaging and invasive assessment of coronary blood flow and coronary vaso-motion (i.e. coronary flow reserve, provocation testing for coronary spasm) may be required. When repeated coronary revascularization is not indicated, therapeutic approaches should aim at targeting the underlying mechanism for the patient's symptoms using a variety of drugs currently available such as beta-blockers, calcium-channel blockers, ivabradine or ranolazine.

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

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

Metabolic agents in the management of diabetic coronary patients: a new era

The modulation of cardiac metabolism with Trimetazidine is very important for the control of myocardial ischemia and for the preservation of left ventricular function. The optimization of cardiac metabolism should also include improvement of cardiac insulin resistance with insulin sensitizer agents and the optimization of Kreb's Cycle with essential amino acids. Regarding new drugs that may act inhibiting free fatty acid oxidation we have to underline that to date it is not clear whether Ranolazine has an effect on cardiac metabolism. We agree instead that metabolic agents like Dichloroacetate, Perhexiline and Etomoxir have an antiischemic effect, while their administration requires adjustment of dose and careful monitoring of side effects.

Trimetazidine added to combined hemodynamic antianginal therapy in patients with type 2 diabetes: a randomized crossover trial

BACKGROUND

In nondiabetic patients with stable angina, combined treatment with hemodynamic agents and trimetazidine is well-tolerated and effective in controlling ischemia. This study aims to evaluate the antiischemic and metabolic effects of trimetazidine in patients with type 2 diabetes mellitus, not eligible for revascularization, who remained symptomatic despite the use of at least 2 antianginal agents.

METHODS

A randomized, double-blind, crossover clinical trial was used. Ten patients were randomized to receive trimetazidine (20 mg, 3 times a day) or placebo for 6-week periods. At baseline and at the end of each 6-week intervention period, clinical and biochemical evaluations, exercise testing, 24-hour ambulatory blood pressure, and Holter monitoring were performed.

RESULTS

During trimetazidine therapy, patients had significant improvement on angina functional class (P < .05), with decrease in the number of weekly angina episodes (1.5 +/- 0.8 vs 0.4 +/- 0.7, P < .01), and in sublingual nitrate doses (1.4 +/- 0.7 mg vs 0.1 +/- 0.3 mg, P < .001). Time to 1-mm ST-segment depression during exercise test was increased after trimetazidine use (229 +/- 126 seconds at baseline, 276 +/- 101 seconds after placebo, and 348 +/- 145 seconds after trimetazidine, P < .001). No differences were observed between treatment periods on mean 24-hour blood pressure, heart rate, and rate-pressure product evaluated concomitantly with ambulatory blood pressure and Holter monitoring. Glycemic and lipid profiles were similar after trimetazidine and placebo use.

CONCLUSIONS

In patients with diabetes who remain symptomatic, the addition of trimetazidine improves symptoms and exercise responses without hemodynamic or metabolic changes. The present data suggest that trimetazidine may be an effective adjunct therapy for these patients, but further investigation is needed to confirm these findings.

Role of trimetazidine in management of ischemic cardiomyopathy

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

Clinical benefits of a metabolic approach with trimetazidine in revascularized patients with angina

As patients with coronary artery disease live longer and more often reach the stage where further myocardial revascularization procedures can no longer be performed, efficacious and well-tolerated antianginal medications are needed. Metabolic agents offer the advantage of controlling symptoms without untoward hemodynamic effects. This article reviews the epidemiology of stable angina and the use of antianginal medications in patients who have undergone myocardial revascularization. It also describes the clinical data on the anti-ischemic effects of metabolic agents in patients undergoing coronary artery bypass surgery or angioplasty, the latter in the setting of acute myocardial infarction and elective procedures. Lastly, the effects of trimetazidine on exercise tests in previously revascularized patients treated with beta-blockers, such as documented in the subgroup analysis of the Second Trimetazidine in Poland (TRIMPOL II) trial, are reported. In all, metabolic agents are likely to be beneficial in revascularized patients, with a documented anti-ischemic effect during myocardial revascularization procedures and the ability to improve exercise tolerance and symptoms in patients with chronic stable angina, despite myocardial revascularization.

Metabolic modulation of myocardial ischemia

The metabolic pathways of the heart during normoxia and ischemia have been well studied. High plasma fatty acid concentrations and the myocardial accumulation of long-chain fatty acyl metabolites during ischemia correlate with increased morbidity and mortality. However, enhanced glucose use can maintain cell homeostasis, diminish ischemic injury, and be clinically beneficial. Metabolic modulators represent a new class of drugs with the potential to treat myocardial ischemia. They are ideal as adjunctive anti-ischemic therapy because they lack the hemodynamic consequences of traditional therapy and treat the underlying metabolic dysfunction that leads to contractile failure and arrhythmias. Clinical studies have demonstrated their efficacy in acute and chronic settings. It is anticipated that there will be greater utilization of this new class of agents in the near future.