Combination treatment with trimetazidine and diltiazem in stable angina pectoris

Objective-To assess antianginal efficacy and possible adverse haemodynamic effects of combination treatment with trimetazidine and diltiazem in patients with stable angina. Design-Double blind, randomised, placebo controlled trial of four weeks duration. Setting-Outpatient department of two Indian hospitals. Subjects-64 male patients with stable angina, uncontrolled on diltiazem alone. Interventions-Diltiazem 180 mg and trimetazidine 60 mg, or diltiazem 180 mg and placebo daily. Main outcome measure-Change in exercise time to 1 mm ST segment depression. Results-33 patients (55%) had no exercise induced angina at 3 mm ST segment depression at inclusion in the study (silent ischaemia). Intention to treat analysis showed that of 32 patients in each treatment group, the number (%) of patients responding to trimetazidine compared to placebo was: for anginal attacks, 28 (87.5) v 15 (46.9), p < 0.001; for exercise time to 1 mm ST segment depression, 21 (65.6) v 9 (28.1), p < 0.003; for exercise time to angina, 12 (37.5) v 5 (15.6), p < 0.05; and for maximum work at peak exercise, 17 (53.1) v 8 (25), p < 0.02. Compared to placebo, there was net improvement with trimetazidine in mean anginal attacks of 4.8/week (95% confidence interval (CI) 7.5 to 2.1; p < 0.002);in mean exercise times at 1 mm ST segment depression of 94.2 seconds (95% CI 182.8 to 5.6; p < 0.05), and at onset of angina of 113.1 seconds (95% CI 181.6 to 44.6; p < 0.02); and in mean maximum work at peak exercise of 1.4 metabolic equivalents (95% CI 2.4 to 0.3; p < 0.05). Conclusions-Patient with stable angina uncontrolled with diltiazem had a clinically important improvement after combination treatment with trimetazidine, without adverse haemodynamic events or increased side effects.