Many alternatives for treating ischemia
and angina: how to choose?
Danchin N, Marzilli M. Efficacy Comparison of Trimetazidine with Therapeutic Alternatives in Stable Angina Pectoris : A Network Meta-Analysis.
Cardiology. 2011. Published online 26 June 2011.
What say European guidelines?
ESC guidelines on angina 2006
Immediate
short-term
relief
Level of evidence
Prognosis
Symptoms
Stable angina for medical management
B
Short-acting sublingual or buccal nitrate, prn
A
Aspirina 75-150 mg od
Clopidogrel 75 mg od
Contraindication e.g. zspirin allergie
Treatment
aimed at
improving
prognosis
B
Statin
 Titrate dose  to get target cholesterol
A
Intolerant or
contraindication
Interchange statins or Ezetimibe with lower dose statin
or replace with alternative lipid-lowering agent
B/C
ACE –inhibitor in proven CVD
A/B
Beta-blocker post-MI
Beta-blocker no prior MI
A
B
A
A
Intolerant (eg fatigue) or contraindication*
Symptoms not controlled after dose
optimization
Calcium antagonist or long-acting nitrate or
K-channel opener or If inhibitor
A/B
Add calcium antigonist or long-acting nitrate
Intolerant
Treatment
aimed at
relief of
symptoms
Symptoms not controlled after dose
optimization
Considerer suitability for revascularization
Symptoms not controlled after dose optimization
Either substitute
alternative subclass of
calcium antagonist or
long-acting nitrate
Combination of nitrate and calcium
antagonist or K-channel opener
Many
alternatives
B/C
Symptoms not controlled or two drugs after dose optimization
Which position
for trimetazidine?
ESC Guidelines.Guidelines on the management on stable angina pectoris. Eur Heart J. 2006
.
A new meta-analysis comparing efficacy
20 000 patients evaluated on exercise tolerance or/and
clinical parameters over 4 weeks
• 218 randomized, controlled, single- or double-blind clinical
trials pooled
• One treatment arm had to include a non-heart-rate-lowering
antianginal agent
•
Given as monotherapy or as combination therapy
• Trials assessed exercise tolerance and/or clinical parameters
• Treatment duration: an average of 4 weeks
Danchin N, Marzilli M. Efficacy Comparison of Trimetazidine with Therapeutic Alternatives in Stable Angina Pectoris : A Network Meta-Analysis.
Cardiology. 2011. Published online 26 June 2011.
Comparison of efficacy: results
• Exercise tolerance
TED = total exercice duration ; T1 = time to 1-mm ST segment depression ; TOA = time to onset of angina.
Trimetazidine is comparable to other drugs in treating
ischemia and angina.
Danchin N, Marzilli M. Efficacy Comparison of Trimetazidine with Therapeutic Alternatives in Stable Angina Pectoris : A Network Meta-Analysis.
Cardiology. 2011. Published online 26 June 2011.
Comparison of efficacy: results
• Clinical parameters
AA = number of angina attacks per week ; SAN = number of short-acting nitrates per week.
Trimetazidine is comparable to other drugs in treating
ischemia and angina.
Danchin N, Marzilli M. Efficacy Comparison of Trimetazidine with Therapeutic Alternatives in Stable Angina Pectoris : A Network Meta-Analysis.
Cardiology. 2011. Published online 26 June 2011.
Conclusion:
how to choose an antianginal agent?
• Trimetazidine is as effective as all its direct antianginal
alternatives, as monotherapy and as combination therapy.1
• Trimetazidine provides a complementary and synergistic
efficiency whatever the other treatments,
→ complete management of ischemic heart disease.
• Moreover, in clinical trials, trimetazidine significantly improved
left ventricular function, suggesting that it may improve
prognosis in patients with stable angina pectoris and chronic
coronary artery disease.2-3
1. Danchin N, Marzilli M. Efficacy Comparison of Trimetazidine with Therapeutic Alternatives in Stable Angina Pectoris : A Network Meta-Analysis.
Cardiology. 2011. Published online 26 June 2011. 2. Lu C, Dabrowski P, Fragasso G, Chierchia SL : Effects of trimetazidine on ischemic left ventricular
dysfunction in patients with coronary artery disease. Am J Cardiol 1998;82:898-901. 3. Shlyakhto EV, Almazov VV, Nifontov EM, Vakhrameyeva IV,
Rudomanov OG, Zakharov DV, et al: Antianginal effects of trimetazidine and left ventricular function improvement in patients with stable angina pectoris.
Am J Cardiovasc Drugs 2002;2:119-124.