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? Many alternatives According to European guidelines, heart-rate-lowering agents can be prescribed as first-line therapy, with beta-blockers representing the first option. Dihydropyridine calcium-channel blockers, long-acting nitrates, nicorandil, and metabolic agents – such as trimetazidine or ranolazine – are recommended as second-line alternatives or as add-on therapies. => Many alternatives are available. How to choose? 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 For the first time, a meta-analysis allows a comparison of the efficacy with of all trimetazidine direct therapeutic alternatives. It pooled 218 randomized, controlled, single- or double-blind clinical trials assessing the treatment of stable angina pectoris or stable ischemic disease. One treatment arm had to include a non-heart-rate-lowering antianginal agent. It could be given as a monotherapy or as a combination therapy. Trials needed to assess exercise tolerance and/or clinical criteria. The average treatment duration was 4 weeks. The meta-analysis enrolled numerous patients, nearly 20 000. Antianginal agent subgroups included in the analysis were dihdropyridines, long-acting nitrates, nicorandil, and ranolazine. 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 Differences on exercise tolerance between trimetazidine and alternative treatments were small and non-significant, be it as monotherapy, or combination therapy (the slide shows overall set). Compared with other antianginal agents, trimetazidine treatment tended to increase total exercise duration by 7 s. Furthermore, compared with placebo, significant differences were noted for all variables tested with an increase in total exercise duration of 46 s. 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 Differences on clinical parameters between trimetazidine and alternative treatments were small and nonsignificant, be it as monotherapy, or combination therapy (the slide shows overall set). Compared with other antianginal agents, trimetazidine treatment tended to decrease the number of angina attacks by 0.28 per week, and short-acting nitrate intake by 0.45 per week. 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 Results of this network meta-analysis show that trimetazidine is as effective as other drugs at treating ischemia and angina, be it as monotherapy or as combination therapy. Due to its unique mode of action trimetazidine provides a complementary and synergistic efficiency whatever the other treatments, that leads to complete management of ischemic heart disease. Moreover, in clinical trials, trimetazidine significantly improved left ventricular function, which suggests it may improve prognosis in patients with stable angina pectoris. 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.