Practical Metabolic Approaches in Chronic Coronary Syndrome and Beyond: Clinical Role of Trimetazidine

The burden of ischemic heart disease has increased globally. In India, the estimated prevalence of angina was around 3.7%. Chronic coronary syndrome, angina pectoris, occurs from an imbalance between oxygen supply and demand in the myocardium. Current antianginal therapies include beta-blockers, calcium channel blockers, nitrates, potassium channel openers, and statins to alleviate symptoms of angina, reduce recurrence, and improve quality of life. Despite conventional therapy, patients remain symptomatic. Hence, there is a need for a new treatment that modulates cardiac energy metabolism and provides promising outcomes in patients with chronic coronary syndrome. Trimetazidine is a metabolic modulator that improves cardiac metabolism by shifting the energy source toward glucose during myocardial ischemia. In this case-based review, we present the role of trimetazidine through hypothetical clinical case scenarios and the clinical evidence of trimetazidine to understand the ideal patient profile. Clinical studies of trimetazidine have demonstrated efficacy in reducing angina frequency, nitrate usage, and improving exercise duration in patients with angina. Trimetazidine could be beneficial as an add-on therapy in patients with chronic coronary syndrome who are inadequately controlled by beta-blockers alone or in combination with other antianginal drugs. Furthermore, trimetazidine is well-tolerated and has been shown to provide survival benefits. Overall, this review could aid practitioners in the use of trimetazidine for different patient indications in clinical cardiology settings in India.