Trimetazidine improves left ventricular function in diabetic patients with coronary artery disease: a double-blind placebo-controlled study

BACKGROUND: Patients with diabetic cardiomyopathy have an impaired myocardial glucose handling and distal distribution of coronary atherosclerosis. Trimetazidine, an anti-ischemic metabolic agent, improves myocardial glucose utilization though inhibition of fatty acid oxidation. Aim of the present study was to evaluate whether the metabolic effect of trimetazidine on left ventricular function in patients with diabetic cardiomyopathy. METHODS: 32 patients (24 males and 8 females, mean (SE) age = 67 ± 6 years) with type 2 diabetes and ischemic cardiomyopathy were randomized to receive either trimetazidine (20 mg, t.d.s.) or placebo (t.d.s.) for six months in a randomized parallel study. Patients performed an echocardiogram at baseline and after 6 months. RESULTS: Demographic data were comparable between the two groups. After six month baseline left ventricular end-diastolic diameters increased from 62.4 ± 1.7 to 63 ± 2.1 mm in the placebo group, while decreased from 63.2 ± 2.1 to 58 ± 1.6 mm (p < 0.01 compared to baseline) in the trimetazidine group. Compared to baseline, left ventricular ejection fraction increased by 5.4 ± 0.5% (p < 0.05) in the trimetazidine group while remained unchanged in the placebo group -2.4 ± 1.1% (NS), p < 0.01 between groups. A significant improvement in wall motion score index and in the E/A wave ratio was detected in patients treated with trimetazidine, but not in those receiving placebo. CONCLUSION: in diabetic patients with ischemic heart disease trimetazidine added to standard medical therapy has beneficial effect on left ventricular volumes and on left ventricular ejection fraction compared to placebo. This effect may be related to the effect of trimetazidine upon cardiac glucose utilization

Metabolic effect of telmisartan and losartan in hypertensive patients with metabolic syndrome

BACKGROUND: Metabolic syndrome is a cluster of common cardiovascular risk factors that includes hypertension and insulin resistance. Hypertension and diabetes mellitus are frequent comorbidities and, like metabolic syndrome, increase the risk of cardiovascular events. Telmisartan, an antihypertensive agent with evidence of partial peroxisome proliferator-activated receptor activity-gamma (PPARγ) activity, may improve insulin sensitivity and lipid profile in patients with metabolic syndrome. METHODS: In a double-blind, parallel-group, randomized study, patients with World Health Organization criteria for metabolic syndrome received once-daily doses of telmisartan (80 mg, n = 20) or losartan (50 mg, n = 20) for 3 months. At baseline and end of treatment, fasting and postprandial plasma glucose, insulin sensitivity, glycosylated haemoglobin (HBA(1c)) and 24-hour mean systolic and diastolic blood pressures were determined. RESULTS: Telmisartan, but not losartan, significantly (p < 0.05) reduced free plasma glucose, free plasma insulin, homeostasis model assessment of insulin resistance and HbA(ic). Following treatment, plasma glucose and insulin were reduced during the oral glucose tolerance test by telmisartan, but not by losartan. Telmisartan also significantly reduced 24-hour mean systolic blood pressure (p < 0.05) and diastolic blood pressure (p < 0.05) compared with losartan. CONCLUSION: As well as providing superior 24-hour blood pressure control, telmisartan, unlike losartan, displayed insulin-sensitizing activity, which may be explained by its partial PPARγ activity

Cardiovascular care of patients with stroke and high risk of stroke: The need for interdisciplinary action: A consensus report from the European Society of Cardiology Cardiovascular Round Table.

Comprehensive stroke care is an interdisciplinary challenge. Close collaboration of cardiologists and stroke physicians is critical to ensure optimum utilisation of short- and long-term care and preventive measures in patients with stroke. Risk factor management is an important strategy that requires cardiologic involvement for primary and secondary stroke prevention. Treatment of stroke generally is led by stroke physicians, yet cardiologists need to be integrated care providers in stroke units to address all cardiovascular aspects of acute stroke care, including arrhythmia management, blood pressure control, elevated levels of cardiac troponins, valvular disease/endocarditis, and the general management of cardiovascular comorbidities. Despite substantial progress in stroke research and clinical care has been achieved, relevant gaps in clinical evidence remain and cause uncertainties in best practice for treatment and prevention of stroke. The Cardiovascular Round Table of the European Society of Cardiology together with the European Society of Cardiology Council on Stroke in cooperation with the European Stroke Organisation and partners from related scientific societies, regulatory authorities and industry conveyed a two-day workshop to discuss current and emerging concepts and apparent gaps in stroke care, including risk factor management, acute diagnostics, treatments and complications, and operational/logistic issues for health care systems and integrated networks. Joint initiatives of cardiologists and stroke physicians are needed in research and clinical care to target unresolved interdisciplinary problems and to promote the best possible outcomes for patients with stroke

Valvular Heart Disease in Heart Failure

Structural valvular heart disease may be the cause of heart failure or may worsen the clinical status of patients with heart failure. Heart failure may also develop in patients treated with valve surgery. Patients with heart failure with valvular heart disease are at increased risk of events including sudden cardiac death. Before considering intervention (surgical or percutaneous) all patients should receive appropriate medical and device therapy taking into account that vasodilators must be used with caution in patients with severe aortic stenosis. Numerous percutaneous and/or hybrid procedures have been introduced in the past few years and they are changing the management of valvular heart disease. In patients with heart failure and valvular heart disease, either primary or functional, the whole process of decision-making should be staged through a comprehensive evaluation of the risk– benefit ratio of different treatment strategies and should be made by a multidisciplinary ‘heart team’ with a particular expertise in valvular heart disease. The heart team should include heart failure cardiologists, cardiac surgeons/structural valve interventionists, imaging specialists, anaesthetists, geriatricians and intensive care specialists. This article will review recent developments and distill practical guidance in the management of this important heart failure co-morbidity

Medical Treatment of Heart Failure with Reduced Ejection Fraction — Aimed at Reducing Re-hospitalisations

The reduction in re-hospitalisation for heart failure is an important therapeutic goal in patients with heart failure, because of the effect of hospitalisations on well- being and prognosis. LCZ696 and ivabradine have been shown not only to reduce events in patients with HFrEF but also to reduce heart failure hospitalisations occurring both as first events, and as recurrent hospitalisations with a similar degree of efficacy. Given the neutral effect of ivabradine on blood pressure, this drug should be always considered in patients in sinus rhythm. LCZ696 has some blood pressure lowering effect that may limit its implementation in some patients. Therefore, in order to fully benefit from the prognostic benefits of these two drugs patients who are still symptomatic after the administration of an ACEi a beta- blocker and a MRA should be switched to these therapies and controlling heart rate with the combination of beta- blockers and ivabradine. Treatments should be implemented with appropriate disease management programs and fluid retention should be monitored with devices like the CardioMEMS that have been proven to effectively reduce events

Medical Treatment of Heart Failure with Reduced Ejection Fraction — Prognostic Indication

An up-to-date review on guideline directed medical therapies that aim to improve prognosis in HFrEF patients. Research on medical interventions that may improve prognosis in patients with chronic heart failure has had great success in the past decades. Therefore, there are well- established classes of drugs — ACEi, beta- blockers, MRAs — that should be used as first line treatment in all patients with heart failure. In the past few years newer therapeutic approaches have been shown to improve prognosis in patients with heart failure but, since the evidence generated by these newer classes of drugs is less than that of the first three classes of drugs these therapies should be implemented only after an initial treatment with the first line drugs has been implemented. This article reviews the advances that have achieved in the treatment of heart failure in terms of a prognostic benefit

The Management of Diabetic Patients with Heart Failure

Patients with diabetes mellitus have an increased risk of developing heart failure and diabetes mellitus is highly prevalent amongst patients with heart failure, especially those with HFpEF. Diabetic patients with heart failure have an increased mortality and an increased risk of hospitalisations and the use of certain anti- diabetic agents increase the risk of mortality and hospitalisation in heart failure. Conversely, newer therapeutic agents have shown a significant reduction of mortality, morbidity and risk of developing heart failure in diabetic patients with proven cardiovascular disease. This highly important area is reviewed in this paper

Medical Treatment of Heart Failure with Reduced Ejection Fraction — Improving Clinical Status and Functional Capacity

A contemporary review of treatments that have been shown to improve functional capacity in patients with Heart Failure and reduced Ejection Fraction (HFrEF). The improvement of functional capacity is one of the main goals of treatment in patients with HFrEF. In the past, despite significant effects on exercise capacity some drugs (e.g. ibopamine, flosequinan) have shown detrimental effects on long- term outcomes in patients with HFrEF. It is perhaps notable that both of these drugs had shown signals of increased safety concerns during the earlier clinical phases of their development. The challenge is to encourage a timely identification of effective treatments that can enhance functional performance in HF without the more difficult and more expensive path to prove all drugs also reduce mortality. It is valuable to have approved and effective treatments that can do the first without the need for the second in all cases, provided adequate safety can be assured. Ivabradine, trimetazidine, ferric carboxymaltose and diuretics have consistently shown to improve functional capacity and symptoms in patients with HFrEF because of their effect on long term prognosis these drugs should always be considered in patients with heart failure. Diuretics improve functional capacity and should be prescribed in patients with signs and symptoms of congestions. Cardiac resynchronisation therapy improves functional capacity in patients with HFrEF in whom it is appropriately applied (QRS >130/150 msec according to morphology)

Treatment of Patients in the Vulnerable Phase (at Discharge or Early After Discharge)

The clinical course of heart failure includes a period in which the patient is at increased risk of death or rehospitalisation for HF. This period is termed the “vulnerable phase” and occurs during the peri-acute HF phase, due to microenvironmental changes in the cardiovascular system. Typically, the vulnerability phase starts from the onset of an acute HF event leading to admission, continues through a peri-discharge period and lasts up to 6 months after discharge.These poor post-discharge outcomes also represent a significant socioeconomic burden. This articles reviews treatments that are beneficial in this important phase