Cardiac magnetic resonance-based evaluation of Trimetazidine's impact on left ventricular global longitudinal strain in stable angina patients with left ventricular dysfunction

Abstract Introduction Trimetazidine (TMZ) is an anti-ischemic metabolic agent recommended as an adjunctive therapy in adults with stable angina pectoris (SA). While left ventricular ejection fraction (LVEF) remains a cornerstone for assessing systolic function, global longitudinal strain (GLS) has emerged as a more sensitive marker for early subclinical myocardial dysfunction. Cardiac magnetic resonance (CMR) offers highly reproducible, operator-independent quantification of both LVEF and GLS, with the latter being derivable from standard cine sequences without the need for additional imaging protocols. This study aimed to investigate whether short-term TMZ therapy could improve LV GLS, as assessed by CMR, in patients with SA, prior myocardial infarction (MI), reduced LVEF, and evidence of viable myocardium. Methods The TRIM-AZ study was a prospective, non-interventional trial conducted in Azerbaijan. Patients with a history of MI, symptomatic stable angina, impaired LVEF, and viable myocardium were included. All patients were on guideline-directed medical therapy (GDMT) prior to enrollment. Participants were randomized to receive either TMZ 80 mg in addition to GDMT or GDMT alone (control group). CMR and transthoracic echocardiography were performed at baseline and at 8 weeks to evaluate changes in both LVEF and GLS. Results A total of 52 patients were enrolled (30 TMZ, 22 control). Baseline characteristics were comparable across groups (mean age 62±7 years; 63% smokers; 60% hypertensive and diabetic). After 8 weeks, no significant change in LVEF was observed in either group as measured by echocardiography or CMR. However, CMR-based GLS showed a statistically significant improvement in the TMZ group (from –9.9%±1.1% to –12.7%±1.2%, p=0.00), whereas the control group did not show significant change (–9.3%±1.3% to –10.3%±1.4%, p=0.3). TMZ was well tolerated with no reported adverse events. Conclusion This study highlights the value of GLS derived from CMR as a sensitive biomarker for detecting early functional improvements in myocardial performance, even when LVEF remains unchanged. The observed enhancement in CMR-GLS following short-term trimetazidine therapy suggests a potential myocardial benefit in patients with stable angina, prior MI, and LV dysfunction with viable myocardium. These findings underscore the importance of incorporating advanced strain imaging into routine CMR protocols to uncover subclinical treatment responses.