Trimetazidine Use in Cardiovascular Disease

Trimetazidine is an antianginal medication approved in numerous countries for use in the symptomatic treatment of stable coronary artery disease and angina pectoris. Its main mechanism of action revolves around the inhibition of β-oxidation of free fatty acids in the myocardium, in addition to its antioxidant properties and inhibition of cardiac fibrosis. Based on current evidence, trimetazidine is classified by European guidelines as a second-line antianginal agent and as an add-on for the symptomatic treatment of stable angina in patients not adequately controlled with first-line antianginal therapies such as beta-blockers. However, its role in the treatment of cardiovascular disease extends past coronary artery disease, as numerous studies have demonstrated its potential benefit in heart failure patients as well. Unfortunately, trimetazidine's role in the treatment of heart failure is still not clearly identified, since most studies on this topic were underpowered and unable to reach a decisive conclusion regarding any potential mortality benefits in heart failure. Current European guidelines have categorized trimetazidine as a class IIb recommendation in patients with heart failure with reduced ejection fraction and angina because of its additive effects of improved left ventricular function and anginal symptom relief in patients already on beta-blockers. Additionally, trimetazidine's use in coronary interventions (ie, percutaneous coronary intervention and coronary artery bypass grafting) showed a reduction in the frequency of anginal attacks and myocardial damage, but the studies were also underpowered and therefore unable to conclusively determine whether trimetazidine should be incorporated in guideline-directed therapy for coronary interventions.