ATPCI: Trimetazidine Fizzles for Post-PCI Angina

Adding trimetazidine to optimum medical therapy doesn’t make stronger outcomes following successful percutaneous coronary intervention (PCI) for staunch angina or a non–ST-elevated myocardial infarction (MI), results of the ATPCI trial picture.

There used to be no merit for the composite foremost endpoint of cardiac death, hospitalization for cardiac occasions, or recurrent/continual angina requiring an addition, swap, or increased dose of antianginal therapies, or requiring coronary angiography (hazard ratio [HR], 0.98; 95% CI, 0.88 – 1.09).

Extra, there had been no between-neighborhood variations in any of the person formula of the endpoint or any prespecified subgroups, Roberto Ferrari, MD, professor of cardiology on the College of Ferrara, Italy, reported in a Hot Line session on the digital European Society of Cardiology (ESC) Congress 2020.

“I mediate one of many the the reason why we couldn’t stare any results used to be in actuality in consequence of this population used to be extremely successfully handled,” he said. “Near to all of them had been receiving either a β-blocker or calcium blocker and, on high of this, they had a successful angioplasty and that’s the reason what we ought to tranquil create, not not up to primarily based totally on ESC guidelines.”

Examine has shown that about 85% to 90% of sufferers enjoy a trade in Unusual York Coronary heart Affiliation angina class within 30 days of PCI, leaving shrimp or no angina leftover to treat, noticed Magnus Ohman, MD, director of the progressed coronary disease program at Duke College, Durham, North Carolina, who used to be not all in favour of the scrutinize.

“The fundamental seek recordsdata from is whether or not or not this used to be the finest scrutinize. Is this agent ineffective, or is it gorgeous that it used to be studied within the heinous population? That to me is in actuality the crux of the topic,” he told theheart.org | Medscape Cardiology.

There is seemingly merit in chronic angina, which shows the extent II advice by the ESC, said Ohman. “Those sufferers assuredly require extra therapy and, within the finest world of treating angina, you want both physiological and metabolic agents to treat angina and trimetazidine is one metabolic agent.”

Trimetazidine will not be available within the united states, nonetheless the anti-ischemic metabolic agent is generally recommended as 2d-line therapy for angina after β-blockers and calcium-channel blockers within the 2019 ESC guidelines on chronic coronary syndrome.

Unlike other customarily outmoded first- and 2d-line antianginal treatment, trimetazidine is devoid of hemodynamic results, Ferrari said. It improves myocardial utilization by favoring glucose to fatty acids, thus allowing anaerobic adenosine triphosphate formation and combating acidosis.

Within the absence of up to the moment recordsdata on the prognostic advantages of antianginal treatment in put up-PCI sufferers, ATPCI investigators at 365 centers in 27 international locations randomly assigned 6007 sufferers with staunch angina or non–ST-section MI after successful non-mandatory or pressing PCI to optimum medical therapy on my own or with trimetazidine, 35 mg modified-release twice on a regular basis.

Sufferers with extreme coronary heart failure, valvular disease, arrhythmia, renal failure or acute ST-elevation MI had been excluded.

Most sufferers (77% male) had Canadian Class Cardiovascular Society class III/IV angina (58%) and had been receiving aspirin plus a P2Y₁₂ inhibitor (97%), lipid-reducing agents (96.6%), renin-angiotensin inhibitors (82.2%), and β-blockers (83.9%). A quarter had been receiving calcium-channel blockers (27.6%). In all, 2517 sufferers had an pressing PCI and 3490 had an non-mandatory PCI.

After a median conform to-up of 47.5 months, the composite foremost endpoint came about in 23.3% of the trimetazidine neighborhood and 23.7% of the withhold watch over neighborhood, primarily based totally on the scrutinize, which used to be printed concurrently in The Lancet.

The incidence of the person formula used to be identical:

Cardiac death: 2.1% vs 2.6% (HR, 0.81)
Well being facility admission for cardiac occasions: 13.4% vs 13.4% (HR, 1.01)
Angina main to coronary angiography: 16.9% vs 16.6% (HR, 1.02)
Angina main to raise/swap in antianginal treatment (HR, 1.01)

There used to be no between-neighborhood incompatibility within the composite main secondary endpoint, which integrated the first endpoint formula plus ischemia main to coronary angiography and an elevate or swap in antianginal therapies. This final result came about in 23.5% and 24.0% of sufferers within the trimetazidine and withhold watch over groups, respectively (HR, 0.98; 95% CI, 0.88 – 1.08).

Results had been also identical when the first endpoint used to be analyzed primarily based totally on whether or not sufferers underwent non-mandatory PCI (HR, 0.94; 95% CI, 0.82 – 1.08) or pressing PCI (HR, 1.04; 95% CI, 0.88 – 1.22), Ferrari reported.

Given the shortcoming of noticed efficacy, trimetazidine has no exercise or plan within the population studied, said Stephan Windecker, the formal discussant for the scrutinize and chair of cardiology at Bern College Well being facility, Switzerland.

“However, I mediate we enjoy to acknowledge that the optimum medical therapy is so potent and has been successfully implemented in this trial that any extra treatment beyond here’s gorgeous unable to reap the benefits of extra merit.”

The scrutinize used to be supported by Servier. Ferrari bought prices, honoraria, and trail charges from Servier. Ohman reports no relevant financial conflicts of ardour. Windecker is an unpaid member of the steering/govt neighborhood for trials funded by Abbott, Abiomed, Amgen, BMS, Boston Scientific, Biotronik, Cardiovalve, Edwards Lifesciences, MedAlliancé, Medtronic, Polares, Sinomed, V-Wave, and Xeltis nonetheless has not bought personal funds from any pharmaceutical or instrument firm.

Lancet. Printed on-line August 30, 2020. Abstract

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