Benefits of adding a energetic agent to -blockers to achieve optimal reduction

of angina.

Review of the main studies

Is coronary obstruction the only player in ischemic heart disease?

Sambuceti G. Eur J Nucl Med Mol Imaging. 2005;32:385-388.

Is coronary obstruction the only player in ischemic heart disease?

Cheng VY, et al. Circulation. 2011;124:2423-2432.

Marzilli M, et al. J Am Coll Cardiol. 2012;60:951-956.

Myocardial ischemia is multifactorial

Marzilli M, et al. J Am Coll Cardiol 2012;60:951–6.

Ischemia is an energy deficiency

Increased energy in the ischemic heart

P=0.04

1,00

1,50

2,00P

cr/A

TP

rat

io

placebo TMZ

+33%

Fragasso G, et al. Eur Heart J. 2006;27:942-948.

Cellular energy balance

Act on both sides of the cellular energy balance

To protect the cells from ischemia, the energy supply needs to remain greater than the energy demand.

Time to 1-mm ST depression

Trimetazidine

Placebo

Time to onset of angina

Angina attacks/week (n) Nitrate use / week (n)

n=426Stable angina patientsAll on metoprolol(50 mg/day)

Szwed H, et al. TRIMPOL II Eur Heart J. 2001;22:2367-2374.

P<0.01

NS

W0 W12

450

400

350

300

Tim

e (

s)

5

2

1

0

4

3

An

gin

a a

ttacks

W0 W12

NS P<0.01

W0 W12

Tim

e (

s)

NS

P<0.01500

400

350

300

450

4

2

1

0

3

Mean

n

itra

te u

se /

week (

n)

W0 W12

NS P<0.01

Proven antianginal efficacy with -blockers

Proven antianginal efficacy with -blockers

Michaelides AP, et al. Clin Drug Invest. 1997;13:8-14.

n=53Stable angina patients uncontrolled withPropranolol 40 mg/day

Proven antianginal efficacy with -blockers

Nesukay E, et al. ESC 2013. Abstract 86728.

Conclusions

Chronic ischemic heart disease (IHD) is still a significant clinical burden

IHD results from a number of mechanisms

To ensure optimal management of IHD on top of -blockers, it is essential to address the energetic origin of ischemia

Trimetazidine MR is an effective drug to use in combination with β-blockers to relieve angina effectively.