Number 27, 2005
Metabolic approach in heart failure

An elderly lady with angina and heart failure – successful response to trimetazidine

Back to the Summary

Graham Jackson
Cardiothoracic Centre, St Thomas' Hospital, London, UK
Correspondence: Dr Graham Jackson, Cardiothoracic Centre, St Thomas' Hospital, London SE1 7EH, UK.
Tel: 020 7188 1055, fax: 0207 357 7408, e-mail: gjcardiol@talk21.com

Case report
Difficult cases often involve multiple pathology, especially in the elderly, but none more so than as exemplified by Mrs J, a 91-year-old widow who lives alone. A patient known to be ischemic, she was admitted to hospital with angina and left ventricular failure. Her pulmonary edema was brought under control with intravenous frusemide but her angina, although stable and not experienced at rest, restricted her walking the few meters along the hospital ward to the toilet. Her routine pathology tests demonstrated normal renal function and blood glucose, a hemoglobin of 13.7g/dL, and normal thyroid function. Her chest X-ray revealed cardiomegaly and, initially, pulmonary edema, which cleared after her diuresis. Her ECG identified left bundle branch block and sinus rhythm (Figure 1) and, although there was no recent chest pain, silent infarction was ruled out by normal concentrations of cardiac enzymes and troponin. An echocardiogram excluded significant aortic and mitral valve disease, but confirmed global left ventricular dysfunction, with an ejection fraction of approximately 15–20%. The patient's admission medication of bisoprolol 1.25mg daily, perindopril 4mg daily, and atorvastatin 10mg daily was continued, along with aspirin 75mg daily. After her daily oral dose of frusemide 40mg had been changed to 80mg, her heart failure remained controlled. Unfortunately, she remained very restricted by her angina, and we did not feel she was able to be independent in her home environment, even though she was mentally very alert and motivated.

Comment
This lady presented a challenge at many levels. We needed to control her heart failure and improve her angina to try to maintain her independence. We were helped by her determination and the various support agencies, but it was the introduction of trimetazidine to her drug regimen that gave us the opportunity to mobilize her sufficiently to facilitate her discharge from hospital. Using echocardiography, which is an essential part of the assessment of heart failure, we ruled out a treatable valvular mechanical cause of her condition (eg, aortic stenosis), and there was no suggestion of atrial fibrillation as a precipitating arrhythmia. It was also important to exclude biochemical causes and “silent“ myocardial infarction.
The importance of a nonhemodynamic metabolic approach to ischemic heart disease has been realized in relation to various clinical ischemic presentations, including diabetes and refractory angina [1]. We now have increasing evidence of the importance and safety of the metabolic agent trimetazidine in the presence of left ventricular dysfunction [2].
Vitale et al [3] studied left ventricular function and quality of life in elderly patients with coronary heart disease. Forty-seven patients with ischemic cardiomyopathy (mean age 78±3 years) received trimetazidine 20mg three times daily or matching placebo, for 6 months. At the end of the study, the trimetazidine group showed significantly improved left ventricular function (systolic and diastolic). In addition, patients receiving trimetazidine showed a greater improvement in angina control and quality of life. Trimetazidine exerts its effects by increasing glucose oxidation and decreasing fatty acid oxidation, which in turn reduces fatty-acid-induced inhibition of pyruvate dehydrogenase [4]. The consequences are increased production of membrane-protective ATP, improved substrate use, and improved cardiac function; the failing heart should thereby be mechanically improved and, at the same time, ischemic pain should be decreased.
The patient described here benefited from this approach, which importantly facilitates a particularly useful noninvasive strategy in patients in an age group who in general prefer a conservative approach to their treatment.

Conclusion
Heart failure (ischemic or nonischemic) has a poor prognosis, no matter what the evidence-based medicine that is optimally deployed. An additional metabolic approach to its management in order to establish whether there is a long-term benefit to morbidity and mortality is certainly worthy of further study [5]. ?

Back to the Summary

REFERENCES

Back to the Summary