Treatment Effects of Bisoprolol and Verapamil in Symptomatic Patients With Non-obstructive Hypertrophic Cardiomyopathy
- Conditions
- Non-obstructive Hypertrophic Cardiomyopathy
- Interventions
- Registration Number
- NCT05569382
- Lead Sponsor
- Morten Steen Kvistholm Jensen
- Brief Summary
Aim: to compare the treatment effects of Bisoprolol (beta 1 receptor specific beta blocker (BB)) and Verapamil (cardio-specific calcium channel blockers (CCB)) in patients with non-obstructive hypertrophic cardiomyopathy (HCM).
Background: Hypertrophic cardiomyopathy (HCM) is characterized by hypertrophy of the left ventricular wall and a hypercontracted state of the sarcomeres. This narrows the left ventricular cavity, but though the left ejection fraction is increased the stroke volume and the cardiac output cannot be fully compensated. The disease manifestations can be mild or develop into severe functional limitations and devastating complications at early age. Dyspnea, chest pain, palpitations and syncope are the most common symptoms, and patients are at risk of supraventricular and ventricular arrhythmias. Arrhythmias and sudden cardiac deaths may precede heart failure symptoms. Patients with symptomatic HCM are treated initially with beta blockers and calcium channel blockers. However, there is limited evidence supporting the effectiveness of this guideline-recommended treatment in HCM.
Methods: The study is a multicenter, double-blinded, randomized, placebo-controlled cross-over trial. Patients are randomized in to three 35-days treatment periods with Bisoprolol, Verapamil and Placebo. Each treatment period includes a 7-days up titration period, a 21-days target dose period and a 7-days down titration period. Between treatment periods 45 days treatment pause is allowed. End point will be evaluated at day 21 (- 4 days). Patients will be evaluated by cardiopulmonary exercise test, echocardiography, 7 day Holter-monitoring, biomarkers and the Kansas City Cardiomyopathy Questionnaire (KCCQ). A subgroup of patients will also be evaluated with cardiac magnetic resonance imaging.
Hypotheses: Three separate phases each with one primary effect parameters will be analyzed between treatment with Bisoprolol and Verapamil:
Phase 1: The maximal oxygen consumption (VO2 max) is different (ΔVO2 max ≥1 ml/kg/min) between treatments in non-obstructive HCM patients Phase 2: The left ventricular enddiastolic volume (LVvol) is different (ΔLVvol ≥3 ml) between treatments in non-obstructive HCM patients.
Phase 3: The incidence of non-sustained ventricular tachycardia (NSVT) is different (Hazard ratio ≥ 0.5) between treatments in non-obstructive HCM patients.
The trial will be performed and analyzed in three phases, and each phase may be unblinded and analyzed separately.
- Detailed Description
Not available
Recruitment & Eligibility
- Status
- RECRUITING
- Sex
- All
- Target Recruitment
- 100
-
Age ≥ 18 years
-
Maximal wall thickness ≥ 15 mm unrelated to hypertension, valve diseases or storage diseases. And one of the following:
- New York Heart Association - functional class (NYHA) ≥ II
- A history of NYHA class ≥ II before treatment with BB or CCB
- Pro-BNP>300 ng/l/35>nmol/l or BNP >100ng/l/>29nmol/l
- Non-sustained VT (>120 min-1, ≥3 cycles) documented within the last 2 years of screening
- Left ventricular ejection fraction < 50%
- LVOT gradient >30 mmHg at rest or during Valsalva maneuver after discontinuation of BB or CCB respectively
- History of LVOT gradient >30 mmHg at rest, during exercise or during Valsalva maneuver.
- Permanent atrial fibrillation
- Permanent right ventricular pacing
- Previous intolerance for Bisoprolol (BB) or Verapamil (CCB)
- Known present obstructive coronary disease (previous percutaneous coronary intervention is accepted)
- eGFR < 40 ml/min
- Fertile women (<50 years) who are pregnant (Positive Plasma-HCG), breastfeeding or not using anticonception.
- Significant liver failure
- Severe valvular disease
- Bradycardia (40bpm)
- Hypotension (systolic <100mmHg)
- Other significant comorbidity or risks associated with discontinuation of BB or CCB after individual judgement by the investigators.
- Unable to understand patient information intellectually or linguistically
- Unable to perform exercise test.
- Unable to speak and/or understand Danish.
Additional exclusion criteria for CMR sub study:
- Implantable cardioverter defibrillator (any kind)
- Pacemaker (any kind)
- Metal implants like to affect image quality
- Metal implants that poses a risk during CMR
- Inability to cope with being in the scanner.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- CROSSOVER
- Arm && Interventions
Group Intervention Description Verapamil Verapamil Maximal tolerable dose (up to 360 mg per day) Bisoprolol Bisoprolol Maximal tolerable dose (up to 7,5 mg per day) Placebo Placebo Matching placebo
- Primary Outcome Measures
Name Time Method Maximal oxygen consumption (VO2 max) Changes will be evaluated at day 21 in each treatment arm Changes in VO2 max estimated during cardiopulmonary exercise test
Left ventricular enddiastolic volume (LVvol) Changes will be evaluated at day 21 in each treatment arm Changes in enddiastolic volume (LVvol) estimated during cardiac MRI
Incidence of non-sustained ventricular tachycardia (NSVT Changes will be evaluated at day 21 +7 days in each treatment arm Changes in NSVT estimated during ECG monitoring
- Secondary Outcome Measures
Name Time Method Canadian Cardiovascular Society (CCS) class Changes will be evaluated at day 21 in each treatment arm Changes in CCS class assessed by clinical evaluation
Echocardiographic left ventricular end-diastolic dimension Changes will be evaluated at day 21 in each treatment arm Changes in left ventricular end-diastolic dimension measured during echocardiography
Echocardiographic dimension of left atrial Changes will be evaluated at day 21 in each treatment arm Changes in left atrial dimension measured during echocardiography
New York Heart Association (NYHA) functional classification Changes will be evaluated at day 21 in each treatment arm Changes in NYHA class assessed by clinical evaluation
Pro-BNP/BNP Changes will be evaluated at day 21 in each treatment arm Changes in level of Pro-BNP/BNP in blood sample
Echocardiographic global longitudinal strain (GLS) for LV function Changes will be evaluated at day 21 in each treatment arm Changes in GLS measured during echocardiography
High sensitive Troponin I/Troponin T Changes will be evaluated at day 21 in each treatment arm Changes in level of high sensitive Troponin I/Troponin T in blood sample
Recovery time Changes will be evaluated at day 21 in each treatment arm Changes in recovery time measured during cardiopulmonary exercise test
VO2 max Anaerobic threshold Changes will be evaluated at day 21 in each treatment arm Changes in VO2 max at anaerobic threshold measured during cardiopulmonary exercise test
Percent predicted VO2 max Changes will be evaluated at day 21 in each treatment arm Changes in percent predicted VO2 max measured during cardiopulmonary exercise test
Left ventricular systolic function on Cardiac MRI Changes will be evaluated at day 21 in each treatment arm Changes in left ventricular systolic function on Cardiac MRI
Right ventricular dimensions on Cardiac MRI Changes will be evaluated at day 21 in each treatment arm Changes in right ventricular dimensions on Cardiac MRI
Right ventricular systolic function on Cardiac MRI Changes will be evaluated at day 21 in each treatment arm Changes in right ventricular systolic function on Cardiac MRI
Sex specific analyses of outcome measures Changes will be evaluated at day 21 in each treatment arm Changes in outcome measures between male and female
Kansas City Cardiomyopathy Questionnaire (KCCQ) score Changes will be evaluated at day 21 in each treatment arm Changes in KCCQ assessed by clinical evaluation
Metabolic equivalent of task (METs) Changes will be evaluated at day 21 in each treatment arm Changes in METs measured during cardiopulmonary exercise test
Ventilatory equivalent for carbon dioxide VE/VCO2 Changes will be evaluated at day 21 in each treatment arm Changes in VE/VCO2 measured during cardiopulmonary exercise test
Episodes of atrial fibrillation (AFIB) on Holter monitoring Changes will be evaluated at day 21 +7 days in each treatment arm Changes in episodes of AFIB measured during Holter monitoring
Dimension of inferior and superior caval vein on Cardiac MRI Changes will be evaluated at day 21 in each treatment arm Changes in dimension of inferior and superior caval vein on Cardiac MRI
Dimension of left atrium on cardiac MRI Changes will be evaluated at day 21 in each treatment arm Changes in dimension of left atrium on cardiac MRI
Number of ventricular ectopic beats on Holter monitoring Changes will be evaluated at day 21 +7 days in each treatment arm Changes in number of ventricular ectopic beats measured during Holter monitoring
Echocardiographic left ventricular outflow tract time velocity intergral (LVOT VTI) for LV function Changes will be evaluated at day 21 in each treatment arm Changes in LVOT VTI measured during echocardiography
Stroke volume (Aortic flow) on Cardiac MRI Changes will be evaluated at day 21 in each treatment arm Changes in stroke volume (Aortic flow) on Cardiac MRI
Coronary sinus flow on Cardiac MRI Changes will be evaluated at day 21 in each treatment arm Changes in coronary sinus flow on Cardiac MRI
Trial Locations
- Locations (4)
Department of Cardiology, Aarhus University Hospital
🇩🇰Aarhus N, Denmark
Department of Cardiology, Odense University Hospital
🇩🇰Odense, Denmark
Department of Cardiology, Zealand University Hospital
🇩🇰Roskilde, Denmark
Department of Cardiology, Regional Hospital Viborg
🇩🇰Viborg, Denmark