1. How do we further reduce angina in patients already treated with a hemodynamic agent? Benefits of adding a metabolic agent to other antianginal drugs (  -blockers, CCBs, nitrates…) in the treatment of stable angina International Journal of Cardiology - 2014 Peng S et al. Int J Cardiol. 2014;177(3):780-785.

2. Prof Peng meta-analysis Methodology  13 randomized, controlled, clinical trials gathering 1628 patients  Assessing the efficacy of a metabolic agent in combination with other antianginal drugs (  -blockers, CCBs, nitrates…) vs other antianginal drugs in the treatment of stable angina  Treatment duration: 4 to 24 weeks End points:  Clinical and ergometric parameters Peng S et al. Int J Cardiol. 2014;177(3):780-785.

3. Prof Peng meta-analysis Results Weekly mean number of angina attacks WMD (95% CI) Adding a metabolic agent to other antianginal agents, significantly Decreases weekly number of angina attacks Decreases weekly nitrates consumption P < 0.001 - 0.95 Peng S et al. Int J Cardiol. 2014;177(3):780-785.

4. Prof Peng meta-analysis Results weekly mean number of angina attacks WMD (95% CI) TOTAL WORK WMD (95% CI) P < 0.001 0.82 P < 0.001 49.81 EXERCISE DURATION WMD (95% CI) Adding a metabolic agent to other antianginal agents, significantly Increases total work at peak exercise by 0.82 METs Increases exercise duration at peak exercise by 49.81 seconds Peng S et al. Int J Cardiol. 2014;177(3):780-785.

5. Prof Peng meta-analysis Discussion According to the authors: -“A metabolic agent optimizes cardiac metabolism, leading to an increase in the cell’s tolerance to ischemia” -“A metabolic agent combined with hemodynamic agents offers full additional efficacy while preserving tolerability” -“In contrast, studies pointed out the absence or little benefit provided by combined hemodynamic agents. This indicates the superiority of a metabolic agent as an adjunct treatment for stable angina pectoris” Peng S et al. Int J Cardiol. 2014;177(3):780-785.

6. Prof Peng meta-analysis Conclusion This meta-analysis confirms, in a large population, the efficacy of a metabolic agent in reducing angina and improving exercise capacity in angina patients. Moreover, it illustrates a fully additive efficacy of metabolic agent when combined with hemodynamic agents. Benefits of metabolic agent appear in the short term and are maintained in the long term. Peng S et al. Int J Cardiol. 2014;177(3):780-785.