Clinical benefits of a metabolic approach in the management of coronary patients.

Patients with Angina Pectoris benefit from therapy with nitrates, beta-blockers, and calcium channel antagonists. All these drugs, through different action mechanisms, tend to reduce cardiac work and restore the balance between myocardial metabolic demand and blood supply. Failure of this conventional haemodynamic treatment in controlling symptoms and preventing ischemia is however frequent, and many such patients are then referred for myocardial revascularization. This scenario has been innovated by Trimetazidine, an anti-ischemic agent that exerts its beneficial effects by increasing cell tolerance to ischemia and improving functional recovery at the time of reperfusion. Compared with classic "hemodynamic" agents, Trimetazidine demonstrated similar efficacy in reducing frequency and severity of ischemic attacks and in increasing exercise tolerance, with a lower incidence of side effects. The adjunct of Trimetazidine to propranolol was found superior to nitrates in reducing ischemic episodes. In angina patients not controlled by CA-antagonists, Trimetazidine lowered the frequency of ischemic attacks and prolonged the time to ischemia during exercise. More recently, Trimetazidine has been shown to improve left ventricular dysfunction in patients with congestive heart failure, and in ischemic patients undergoing PTCA. In chronic coronary artery disease, Trimetazidine improved regional dysfunction at rest and during dobutamine stress echocardiography. Given the metabolic mechanism of action of Trimetazidine, focused on improving energy metabolism and restoring membrane homeostasis, it is expected to especially benefit patients in whom metabolic alteration contribute to the pathogenesis of ischemia, namely diabetic patients. Preliminary data from a multicenter study do support this hypothesis. In conclusion, available data indicate that the cardioprotective effect of Trimetazidine results in improvement of symptoms and preservation of left ventricular function in patients with acute and chronic ischemic syndromes.