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.
Myocardial ischemia is multifactorial
Marzilli M, et al. J Am Coll Cardiol. 2012;60:951-956.
Ischemia is an energy deficiency
Marzilli M, et al. J Am Coll Cardiol 2012;60:951–6.
Increased energy in the ischemic heart
+33%
P c r/A T P ra tio
2 ,0 0
P = 0 .0 4
1 ,5 0
1 ,0 0
p la c e b o
Fragasso G, et al. Eur Heart J. 2006;27:942-948.
TM Z
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.
Cellular energy balance
Proven antianginal efficacy with -blockers
Time to 1-mm ST depression
450
Time to onset of angina
500
P<0.01
P<0.01
Time (s)
Time (s)
450
400
NS
350
400
n=426
Stable angina patients
All on metoprolol
(50 mg/day)
NS
350
300
W0
W12
300
5
NS
P<0.01
Angina attacks
4
3
2
1
0
W0
W12
Nitrate use / week (n)
Mean nitrate use / week (n)
Angina attacks/week (n)
W0
W12
Szwed H, et al. TRIMPOL II Eur Heart J. 2001;22:2367-2374.
4
NS
P<0.01
3
2
1
0
W0
W12
Trimetazidine
Placebo
Proven antianginal efficacy with -blockers
n=53
Stable angina patients
uncontrolled with
Propranolol 40 mg/day
Michaelides AP, et al. Clin Drug Invest. 1997;13:8-14.
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.