Harnessing Cardiac Energetics in the Treatment of Heart Failure
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Background: The prevalence of heart failure in India is not clearly known, in developed societies it is about 1 per cent of the elderly population (above 65 years) and is responsible for 20 per cent of all hospital admissions in this age group. Clinical trials that included ACEI, ARBs, beta-blockers and aldosterone antagonists have demonstrated substantial reduction in mortality in patients with systolic heart failure, but still the mortality remains high.
Aim: To recognize the altered energetics that play an important role in the mechanism of heart failure, role of cardiac metabolism and metabolic agents such as trimetazidine in the treatment of heart failure.
Results: Progression of heart failure leads to metabolic changes causing change in relative substrate utilization of fatty acids (60 to 90%) and glucose (10 to 40%) leading to a substantial reduction of ATP synthesis in the failing myocardium. Trimetazidine which is the most studied among the metabolic agents has shown to prefer glucose oxidation to fatty acid, significantly improving ATP synthesis by +33%. Randomized trials of trimetazidine have shown improvement in ejection fraction, 7 –23%, NYHA class, hospitalization and mortality reduction by 30%.
Conclusion: Metabolic management offers fresh insights and among the metabolic agents available trimetazidine is the most documented. Trimetazidine has shown to improve cardiac function without affecting the heart rate or blood pressure. The mortality benefit and improvement in hospitalization frequency suggested need to be confirmed in larger randomized studies.