Vasodilator Therapy for Heart Failure and Preserved Ejection Fraction

Phase 2

Completed

Conditions: Congestive Heart Failure
Heart Failure

Interventions: Drug: Placebo
Drug: Isosorbide Dinitrate + Hydralazine
Drug: Isosorbide Dinitrate

Registration Number: NCT01516346

Lead Sponsor: Corporal Michael J. Crescenz VA Medical Center

Brief Summary: The main objective is to test the effect of prolonged therapy (24 weeks) with isosorbide dinitrate ± hydralazine on arterial wave reflections (primary endpoint). Secondary endpoints include left ventricular (LV) mass, fibrosis and diastolic function) and exercise capacity (assessed via the 6-minute walk test) in patients with Heart Failure and Preserved Ejection Fraction (HFPEF). We will also test the hypothesis that the reduction in arterial wave reflections induced by vasoactive therapy will correlate with the improvement in exercise capacity, LV mass, fibrosis and diastolic function. Finally, we will assess whether the hemodynamic response to an acute dose of sublingual nitroglycerin (NTG) can predict the sustained changes in the reflected wave and other hemodynamic parameters in response to chronic vasodilator therapy.

Detailed Description: Not available

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 44

Inclusion Criteria

Previous clinical diagnosis of heart failure with current New York Heart Association Class II-IV symptoms.
LV ejection fraction >50% on a clinically indicated echocardiogram or ventriculogram within 12 months prior to consent, in the absence of a change in cardiovascular status, as assessed by the principal investigators.
Must have had at least one of the following within the 12 months prior to consent
1. Hospitalization for decompensated HF
2. Acute treatment for HF with intravenous loop diuretic or hemofiltration.
3. Chronic treatment with a loop diuretic for control of HF symptoms.
4. Chronic diastolic dysfunction on echocardiography as evidenced by left atrial enlargement or at least stage II diastolic dysfunction.
5. Documentation of elevated NT-pro BNP levels or other natriuretic peptide marker (BNP, ANP) according to the laboratory and assay upper limit of normal in the previous year.
Stable medical therapy as defined by:
1. No addition or removal of ACE, ARB, beta-blockers, or calcium channel blockers (CCBs) for 30 days.
2. No change in dosage of ACE, ARBs, beta-blockers or CCBs of more than 100% for 30 days.
3. No change in diuretic dose for 10 days.

Exclusion Criteria

Rhythm other than sinus rhythm (i.e., atrial fibrillation).
Neuromuscular, orthopedic or other non-cardiac condition that prevents patient from walking in a hallway.
Non-cardiac condition limiting life expectancy to less than one year, per physician judgment.
Current or anticipated future need for nitrate therapy.
Valve disease (> mild aortic or mitral stenosis; > moderate aortic or mitral regurgitation).
Hypertrophic cardiomyopathy.
Known infiltrative or inflammatory myocardial disease (amyloid, sarcoid).
Pericardial disease.
Primary pulmonary arteriopathy.
Have experienced a myocardial infarction or unstable angina, or have undergone percutaneous transluminal coronary angiography (PTCA) or coronary artery bypass grafting (CABG) within 60 days prior to consent, or requires either PTCA or CABG at the time of consent.
Other clinically important causes of dyspnea such as morbid obesity or significant lung disease defined by clinical judgment or use of steroids or oxygen for lung disease.
Systolic blood pressure < 110 mmHg or > 180 mm Hg.
Diastolic blood pressure < 40 mmHg or > 100 mmHg.
Resting heart rate (HR) > 100 bpm.
A history of reduced ejection fraction (EF<50%).
Severe renal dysfunction (estimated GFR <30 ml/min/1.73m2 by modified MDRD equation) GFR (mL/min/1.73 m2) = 175 x (Scr)-1.154 x (Age)-0.203 x (0.742 if female) x (1.210 if African American) (conventional units), which would impede the safe administration of gadolinium for MRI studies contrast.
Hemoglobin <10 g/dL.
Patients with known severe liver disease (AST > 3x normal, alkaline phosphatase or bilirubin > 2x normal).
Patients with a clinically indicated stress test demonstrating significant ischemia within a year of enrollment which was not followed by percutaneous or surgical revascularization.
Listed for cardiac transplantation.
Allergy to isosorbide dinitrate or hydralazine.
Current therapy with phosphodiesterase inhibitors, such as sildenafil, vardenafil or tadalafil, since the combination of nitrates and phosphodiesterase inhibitors can result in severe hypotension.
We will also exclude patients who are not suitable candidates for a cardiac MRI by virtue of having the following absolute or relative contraindications: (i) Central nervous system aneurysm clips; (ii) Implanted neural stimulators; (iii) Implanted cardiac pacemaker or defibrillator; (iv) Cochlear implant; (v) Ocular foreign body (e.g. metal shavings); (vi) Other implanted medical devices: (e.g. drug infusion ports); (vii) Insulin pump; (viii) Metal shrapnel or bullet; (ix) Claustrophobia; (x) Extreme obesity rendering the patient unable to fit into narrow-bore scanners; (xi) Unwillingness of the patient to undergo a cardiac MRI. All patients with metallic implants will be individually evaluated prior to MRI.

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Placebo	Placebo	Research pharmacy-formulated capsules will be given to subjects in two bottles. For this interventional arm, both the bottles will contain placebo capsules. Dosage will be same regardless of up-titration from Stage 1 dosing to Stage 2 dosing. Frequency is three times daily, to be taken at 8 AM, 2 PM and 8 PM. Duration is for 24 weeks.
Isosorbide dinitrate + Hydralazine	Isosorbide Dinitrate + Hydralazine	Research pharmacy-formulated capsules will be given to the subjects in two bottles. For this interventional arm, one of the bottles will contain the active ingredient Isosorbide Dinitrate and the other will contain the active ingredient Hydralazine. Dosage of Isosorbide Dinitrate will be 20mg (if Stage 1) OR 40mg (if Stage 2). All the subjects will be uptitrated to Stage 2 dosing, if they tolerate Stage 1 dosing. Frequency is three times daily to be taken at 8 AM, 2 PM and 8 PM. Duration is for 24 weeks. Dosage of Hydralazine will be 37.5mg (if Stage 1) OR 75mg (if Stage 2). All the subjects will be uptitrated to Stage 2 dosing, if they tolerate Stage 1 dosing. Frequency is three times daily, to be taken at 8 AM, 2 PM and 8 PM. Duration is for 24 weeks.
Isosorbide dinitrate	Isosorbide Dinitrate	Research pharmacy-formulated capsules will be given to the subjects in two bottles. For this interventional arm, one of the bottles will contain the active ingredient Isosorbide Dinitrate and the other will contain placebo capsules. Dosage of Isosorbide Dinitrate will be 20mg (if Stage 1) OR 40mg (if Stage 2). All the subjects will be uptitrated to Stage 2 dosing, if they tolerate Stage 1 dosing. Frequency is three times daily to be taken at 8 AM, 2 PM and 8 PM. Duration is for 24 weeks.

Primary Outcome Measures

Name	Time	Method
Wave Reflection Magnitude	24 weeks	The dimensionless ratio of backward (reflected) to forward wave amplitude. Higher values imply more wave reflection.

Secondary Outcome Measures

Name	Time	Method
LV Mass	24 weeks	LV mass measured by MRI, in grams normalized to height in meters raised to the 1.7 power (m\^1.7)
Quality of Life (Kansas City Cardiomyopathy Questionnaire Score)	24 weeks	Quality of life, assessed with the Kansas City cardiomyopathy questionnaire (overall summary score, which ranges from 0 to 100). Higher values imply better quality of life.
Early Diastolic Mitral Annular Velocity	24 weeks	Diastolic mitral annular velocity measured at the basal septal mitral annulus
Myocardial Extracellular Volume Fraction	24 weeks	Myocardial extracellular volume, expressed as percent of total tissue volume, measured by MRI (T1 mapping pre and post-gadolinium administration)