Personalized management of angina and heart failure in clinical practice in the Middle East: a narrative review

More interventions that better manage cardiovascular disease are urgently needed in the Middle East. To discuss this issue, we held a symposium at the Heart Masters Middle East 2023 congress (Dubai, UAE; May 2023) on personalized management of angina and heart failure (HF). This narrative review summarizes the content of our symposium. Many patients with chronic stable angina have ongoing symptoms and poor quality of life (QoL) despite beta-blocker + calcium-channel blocker therapy and revascularization. Further, angina is often under-recognized in clinical practice. Clinicians should consider adding newer antianginal agents (long-acting nitrates, ranolazine, trimetazidine, ivabradine) to beta-blockers + calcium-channel blockers based on patient risk factors. Individualized therapy is recommended because several mechanisms can cause angina. Agents that act at a cellular level (e.g., trimetazidine) can prevent ischemia in cardiomyocytes. Trimetazidine provides early and sustained antianginal effects, with improvements in myocardial metabolism and exercise capacity. In our view, trimetazidine may be considered as second-line therapy for angina that is suboptimally controlled on first-line therapy, and could be added to first-line therapy for angina occurring after myocardial infarction or revascularization, and comorbid with diabetes. Ivabradine reduces elevated heart rate and, when added to beta-blockers, improves angina symptoms, exercise capacity and QoL. Few patients with HF with reduced ejection fraction receive medications at target doses. Guidelines suggest rapid initiation of first-line agents from four drug classes, with a simultaneous strategy favored over a sequential one. In patients with HF with reduced ejection fraction in sinus rhythm and elevated heart rate, ivabradine should be added to maximum tolerated doses of beta-blockers. Adding ivabradine to first-line therapy improves heart rate control and QoL, and reduces HF-related hospitalization and mortality.