Early initiation of Trimetazidine effective for managing heart disease in diabetes patients: JAPI Review.
The use of trimetazidine as an adjunct treatment for relieving angina can significantly improve clinical outcomes in patients with type 2 diabetes (T2D), a recent review has shown. The review article published in the Journal of the Association of Physicians of India supports the current clinical practice guidelines that recommend trimetazidine as a first-line agent for selected patients or as a second-line treatment option for angina patients.
Diabetes is a metabolic disease that causes high blood sugar levels. It is a global health problem -- according to estimates, 463 million people were affected by diabetes in 2019 and the numbers are expected to rise to 700 million by 2045. Diabetes patients are at two- to four-fold increased risk for CV events compared to people without diabetes.
In diabetes patients, differential presentation of CV disease is related to metabolic derangement that leads to deterioration of myocardial cell function and its serious consequences. For correcting this myocardial cell metabolic dysfunction, there is a need for early and effective treatment intervention.
Myocardial ischemia (MI) and diabetes share a common metabolic dysregulation mediated via increased fatty acid oxidation that makes the diabetic heart susceptible to myocardial ischemia and reduced myocardial performance during ischemia compared to the non-diabetic heart. Considering this, the key target for metabolic interventions in patients with Diabetic CV complications should be the modulation of myocardial free fatty acid metabolism.
Trimetazidine is a fatty acid metabolic modulator that has shown to improve CV outcomes in diabetes patients. With this background, senior cardiologists Dr Sharvari Mahajan and Dr AU Mahajan from LTMMC, Mumbai reviewed the clinical evidence on trimetazidine as an anti-anginal and anti-ischemic agent in diabetes patients.
The review published in JAPI highlights the benefits of trimetazidine in various clinical conditions.
Patients with stable CAD and DM
Trimetazidine has been studied thoroughly for its safety and efficacy in diabetes patients with CAD (coronary artery disease). Trimetazidine alone or as add-on to conventional anti-anginal agents is effective in treating stable angina.
The TRIMetazidine in POLand-1 (TRIMPOL-1) study showed significantly improved exercise-induced ischemia and time to onset of angina, and decreased severity and the intensity of angina pain. Another study, the DIETRIC study reported a significant reduction in angina episodes and the number of nitroglycerin tablets used per week, and improvement in all exercise parameters.
Patients with left ventricular dysfunction
Trimetazidine was shown to improve endothelium-dependent relaxation and decreased systemic oxidative marker levels in patients with CHF secondary to ischemic cardiomyopathy in a study by Belardinelli et al. A meta-analysis of 17 clinical trials showed trimetazidine therapy to significantly improve left ventricular ejection fraction (LVEF) in patients with both ischemic and non-ischemic HF.
Patients with DM undergoing re-vascularization
In the prospective study, Xu et al reported significant improvement in incidence and severity of angina pectoris, silent Myocardial infarction and angina-free survival in the trimetazidine group compared to those in placebo groups at 2-year follow-up of elderly patients with CHD and DM after drug-eluting stent (DES) implantation.
Further, key points highlighted by the study include:
• Several studies have shown trimetazidine to reduce the number of weekly angina attacks, mean nitroglycerin consumption per week, and time to 1-mm ST-segment depression; and improved ventricular function in patients with DM and stable CAD when used early as an adjunct to other agents.
• Trimetazidine has shown to improve exercise capacity in angina patients and improve the quality of life.
• Trimetazidine has also been suggested as a safe and effective anti-anginal treatment option in persistent angina in presence of HF where it significantly improved left ventricular ejection fraction (LVEF) in patients with both ischemic and non-ischemic HF.
• Peri-procedural and post-DES implantation use of trimetazidine has demonstrated improvement in the incidence and severity of angina pectoris, silent MI, angina-free survival, and PCI-induced myocardial injury.
• Current clinical practice guidelines recommend trimetazidine as a first-line agent for selected patients or as a second-line treatment option for angina patients.
• Early initiation of trimetazidine as an adjunct treatment to relieve angina could be beneficial in patients with non-insulin-dependent DM.
"Evidence suggested that trimetazidine could significantly improve clinical outcomes in patients with angina or heart failure and diabetes. Administering trimetazidine in patients with diabetes undergoing re-vascularization could also provide significant clinical benefits," Dr AU Mahajan told Medical Dialogues Team.
You can read the full review by clicking on the following link
https://www.japi.org/x264a4b4/current-clinical-evidence-of-trimetazidine-in-the-management-of-heart-disease-in-patients-with-diabetes
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