Personalized management of angina and heart failure in clinical practice in the Middle East: a narrative review
Publication: Journal of Comparative Effectiveness Research
Abstract
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.
Plain language summary: Improving personalized care in patients with angina and/or heart failure in the Middle East
What is this article about?
This article summarizes discussions from a workshop on the treatment of cardiovascular disease (CVD) in the Middle East. Ischemic heart disease, which reduces the heart’s ability to pump blood, is a common type of CVD and often causes heart failure (HF). Chest pain (or angina) is a frequent symptom of ischemic heart disease and is caused by reduced blood flow to the heart.
What methodology is described?
A group of specialists in CVD gave presentations based on evidence from the literature and clinical experience, and provided their recommendations for improving personalized care in patients with angina and/or HF.
What was discussed?
Many patients with angina have ongoing symptoms despite standard therapy with beta-blockers and calcium-channel blockers, and procedures to restore the heart’s blood flow. However, other drugs can be added to standard therapy to improve symptoms. For example, trimetazidine improves blood flow and prevents heart muscle damage, and ivabradine reduces heart rate and improves angina symptoms when added to beta-blockers.
Why is this important?
Patients with HF should receive early treatment with multiple medications started together rather than starting one drug class after another, but many patients do not receive appropriate doses of these medications. In patients with HF and an elevated heart rate, addition of ivabradine to standard therapy improves heart rate control and reduces the need for hospitalization due to worsening HF or cardiovascular-related mortality.
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Received: 25 July 2025
Accepted: 11 February 2026
Published online: 12 March 2026
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Personalized management of angina and heart failure in clinical practice in the Middle East: a narrative review. (2026) Journal of Comparative Effectiveness Research. DOI: 10.57264/cer-2025-0119
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