Heart Failure With Preserved Ejection Fraction
Conditions
Brief summary
The purpose of this study is to test whether a ketone ester drink will improve exercise in people with heart failure (HF) compared to a placebo. In HF, patients are limited in their ability to do all the things they want to do, and exercise as much as they would like, due to becoming tired and short of breath early. There may be several reasons why these symptoms occur. There is some evidence that in addition to problems with the heart, patients with HF also have problems with their arteries and muscles that affect their ability to exercise. Ketones have been shown to improve exercise capacity in healthy volunteers, which may be related to effects on the heart function or on muscles. An infusion of ketones through an intravenous (IV) line has also been shown to significantly improve heart function, but whether a drink can produce similar improvements in HF patients is not known. This drink has been given status by Food and Drug Administration as generally regarded as safe. The use of DeltaG in this study is experimental. DeltaG has not been approved by the Food and Drug Administration (FDA) for the use being evaluated in this study.
Detailed description
This is a randomized, crossover trial of ketone ester versus placebo in 20 patients with heart failure with preserved ejection fraction. Participants come for a baseline assessment. If they meet eligibility criteria, they are randomized to receive ketone ester first or placebo first. After approximately a week washout period, participants return for the last visit to receive the product they did not receive at the previous visit.
Interventions
DIETARY_SUPPLEMENTKetone ester
A nutraceutical ketone ester (KE), (R)-3-hydroxybutyl (R)-3-hydroxybutyrate which provides systemic ketosis
DIETARY_SUPPLEMENTplacebo drink
KE free placebo drink
Sponsors
University of Pennsylvania
Study design
Allocation
RANDOMIZED
Intervention model
CROSSOVER
Primary purpose
TREATMENT
Masking
TRIPLE (Subject, Investigator, Outcomes Assessor)
Intervention model description
Overview: The overall study design will be a randomized, double-blind crossover comparison of ketone ester (KE) therapy vs. KE-free vehicle in 20 patients with established HF with preserved ejection fraction (HFpEF). The main outcomes will be measures of exercise performance (peak and submaximal exercise).
Eligibility
Sex/Gender
ALL
Age
18 Years to 85 Years
Healthy volunteers
No
Inclusion criteria
1. Left ventricular ejection fraction ≥ 50% 2. Evidence for elevated filling pressures as follows (at least one of the following between a-d): a. Mitral early (E)/mitral septal tissue annular (e') velocity ratio \> 8 in addition to one of the following: i. Large left atrium (LA\>4.0 cm width or LA volume index \>34 mL/m2) ii. Chronic loop diuretic use for control of symptoms iii. Elevated natriuretic peptides within the past year (NT-proBNP\>125 pg/ml or BNP\>35 pg/ml) b. Mitral E/e' ratio \> 14 at rest or with exercise c. Elevated invasively-determined filling pressures previously (resting left ventricular end-diastolic pressure \>16 mm Hg or pulmonary capillary wedge pressure \> 15 mmHg; or PCWP/LVEDP ≥ 25 mmHg with exercise) d. Prior episode of acute heart failure requiring IV diuretics with evidence of volume overload on exam/radiology or elevated natriuretic peptides.
Exclusion criteria
1. Intentional ketogenic (high fat, low carbohydrate) diet in the last week or use of ketogenic medications (SGLT2 inhibitors) 2. Significant liver disease (liver function tests \> 3x upper limit of normal, cirrhosis) or alcohol abuse disorder (\>14 drinks/week). 3. Contraindications to stress testing, conditions that limit exercise, and other clinically-significant causes of exertional limitation (claudication with peripheral artery disease, atrial fibrillation and heart rate \>110 at rest, systolic blood pressure\>180 mmHg or diastolic blood pressure\>110 mmHg, infiltrative/hypertrophic/inflammatory cardiomyopathy, clinically significant pericardial disease, joint or neuromuscular disease that precludes exercise, acute coronary syndrome within the last 2 months, estimated glomerular filtration rate\<30 mL/min/1.73 m2, and hemoglobin \< 9 mg/dL). 4. Clinically significant lung disease. This would be defined by severe obstructive lung disease (Gold stage 3), a requirement for supplemental oxygen, or chronic obstructive pulmonary disease with an exacerbation requiring steroids or antibiotics within the last 2 months. 5. \>= Moderate aortic stenosis, \>mild mitral stenosis, \>= moderate aortic or mitral regurgitation on screening echocardiogram 6. Type 1 diabetes mellitus 7. Pregnant women. Due to unknown affects of nutritional ketosis in pregnant women, pregnancy will be an exclusion. Accordingly, women of childbearing age with a menstrual cycle within the past year will be asked to submit a urine specimen for pregnancy testing. 8. Angina due to epicardial coronary disease or known presence of clinically-significant, unrevascularized epicardial coronary disease, in the investigator's opinion. 9. Prior reduced LVEF to \< 45%
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Maximal Exercise Capacity (Peak VO2) Assessed by Cardiopulmonary Exercise Testing | Assessed 60 minutes after the intervention. | Peak VO2 |
| Submaximal Exercise Capacity (Exercise Time at 75% of Peak Workload) Assessed by Cardiopulmonary Exercise Testing. | Assessed 30 minutes after the intervention. | Exercise time at 75% of peak workload |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Percent Change in Systemic Vascular Resistance With Exercise | Assessed 60 minutes after the intervention. | Percent change in systemic vascular resistance with exercise |
| Substrate Utilization (Reflected by the Respiratory Exchange Ratio) Assessed by Cardiopulmonary Exercise Testing. | Assessed 60 minutes after the intervention. | — |
| VO2 Efficiency (Total Work Performed Over Oxygen Consumed) During Submaximal Cardiopulmonary Exercise Testing. | Assessed 60 minutes after the intervention. | — |
| Presence of Exercise-induced Arrhythmias (Significant Atrial or Ventricular Arrhythmias) | Assessed throughout the study visit date after the intervention is given (until leaving the research study center that day). | — |
Countries
United States
Participant flow
Pre-assignment details
Out of 26 consented participants, 5 screen failed and 1 participant withdrew, leading to 20 randomized participants.
Participants by arm
| Arm | Count |
|---|---|
| Randomized First to Ketone Ester (R)-3-hydroxybutyl (R)-3-hydroxybutyrate, a ketone ester
Ketone ester: A nutraceutical ketone ester (KE), (R)-3-hydroxybutyl (R)-3-hydroxybutyrate which provides systemic ketosis.
10 individuals were randomized to ketone ester first, and 10 individuals were randomized to placebo first. | 10 |
| Randomized First to Placebo KE-free solution
placebo drink: KE free placebo drink.
10 individuals were randomized to ketone ester first, and 10 individuals were randomized to placebo first. | 10 |
| Total | 20 |
Baseline characteristics
| Characteristic | Randomized First to Placebo | Total | Randomized First to Ketone Ester |
|---|---|---|---|
| Age, Continuous | 71 years STANDARD_DEVIATION 10 | 71 years STANDARD_DEVIATION 8 | 71 years STANDARD_DEVIATION 7 |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 4 Participants | 7 Participants | 3 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) White | 6 Participants | 13 Participants | 7 Participants |
| Sex: Female, Male Female | 6 Participants | 12 Participants | 6 Participants |
| Sex: Female, Male Male | 4 Participants | 8 Participants | 4 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 20 | 0 / 20 |
| other Total, other adverse events | 7 / 20 | 6 / 20 |
| serious Total, serious adverse events | 1 / 20 | 0 / 20 |
Outcome results
Primary
Maximal Exercise Capacity (Peak VO2) Assessed by Cardiopulmonary Exercise Testing
Peak VO2
Time frame: Assessed 60 minutes after the intervention.
Population: All 20 participants contributed to the data. 10 participants started first in the ketone ester group and then crossed over to placebo, while 10 participants started first in the placebo arm and crossed over the ketone ester.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Ketone Ester | Maximal Exercise Capacity (Peak VO2) Assessed by Cardiopulmonary Exercise Testing | 1.0 L/min | Standard Deviation 0.3 |
| Placebo | Maximal Exercise Capacity (Peak VO2) Assessed by Cardiopulmonary Exercise Testing | 1.0 L/min | Standard Deviation 0.3 |
Primary
Submaximal Exercise Capacity (Exercise Time at 75% of Peak Workload) Assessed by Cardiopulmonary Exercise Testing.
Exercise time at 75% of peak workload
Time frame: Assessed 30 minutes after the intervention.
Population: All 20 participants contributed to the data. 10 participants started first in the ketone ester group and then crossed over to placebo, while 10 participants started first in the placebo arm and crossed over the ketone ester.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Ketone Ester | Submaximal Exercise Capacity (Exercise Time at 75% of Peak Workload) Assessed by Cardiopulmonary Exercise Testing. | 9.7 minutes | Standard Deviation 7.3 |
| Placebo | Submaximal Exercise Capacity (Exercise Time at 75% of Peak Workload) Assessed by Cardiopulmonary Exercise Testing. | 8.7 minutes | Standard Deviation 4.3 |
Secondary
Percent Change in Systemic Vascular Resistance With Exercise
Percent change in systemic vascular resistance with exercise
Time frame: Assessed 60 minutes after the intervention.
Population: All participants with available data (13 in ketone ester group and 14 in the placebo group) shown here.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Ketone Ester | Percent Change in Systemic Vascular Resistance With Exercise | -21.5 Percent change from rest to peak exercis | Standard Deviation 14.7 |
| Placebo | Percent Change in Systemic Vascular Resistance With Exercise | -34.2 Percent change from rest to peak exercis | Standard Deviation 11.5 |
Secondary
Presence of Exercise-induced Arrhythmias (Significant Atrial or Ventricular Arrhythmias)
Time frame: Assessed throughout the study visit date after the intervention is given (until leaving the research study center that day).
Population: All 20 participants contributed to the data. 10 participants started first in the ketone ester group and then crossed over to placebo, while 10 participants started first in the placebo arm and crossed over the ketone ester.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Ketone Ester | Presence of Exercise-induced Arrhythmias (Significant Atrial or Ventricular Arrhythmias) | 0 Participants |
| Placebo | Presence of Exercise-induced Arrhythmias (Significant Atrial or Ventricular Arrhythmias) | 0 Participants |
Secondary
Substrate Utilization (Reflected by the Respiratory Exchange Ratio) Assessed by Cardiopulmonary Exercise Testing.
Time frame: Assessed 60 minutes after the intervention.
Population: All 20 participants contributed to the data. 10 participants started first in the ketone ester group and then crossed over to placebo, while 10 participants started first in the placebo arm and crossed over the ketone ester.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Ketone Ester | Substrate Utilization (Reflected by the Respiratory Exchange Ratio) Assessed by Cardiopulmonary Exercise Testing. | 1.09 Ratio | Standard Deviation 0.13 |
| Placebo | Substrate Utilization (Reflected by the Respiratory Exchange Ratio) Assessed by Cardiopulmonary Exercise Testing. | 1.14 Ratio | Standard Deviation 0.14 |
Secondary
VO2 Efficiency (Total Work Performed Over Oxygen Consumed) During Submaximal Cardiopulmonary Exercise Testing.
Time frame: Assessed 60 minutes after the intervention.
Population: All 20 participants contributed to the data. 10 participants started first in the ketone ester group and then crossed over to placebo, while 10 participants started first in the placebo arm and crossed over the ketone ester.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Ketone Ester | VO2 Efficiency (Total Work Performed Over Oxygen Consumed) During Submaximal Cardiopulmonary Exercise Testing. | 6.0 kJ/L O2 | Standard Deviation 2.6 |
| Placebo | VO2 Efficiency (Total Work Performed Over Oxygen Consumed) During Submaximal Cardiopulmonary Exercise Testing. | 6.1 kJ/L O2 | Standard Deviation 2.9 |