Cerebral Small Vessel Diseases, Stroke
Conditions
Keywords
Cerebral Small Vessel Diseases, Stroke recurrence, Hypertension, Homocysteine, Folic acid
Brief summary
The primary objectives of this trial are: 1. Efficacy evaluation of amlodipine folic acid tablets: To assess the effects of amlodipine folic acid tablets 5.8 mg (5 mg amlodipine + 0.8 mg folic acid)versus amlodipine tablets 5 mg in preventing all-cause stroke in cerebral small vascular disease (CSVD) patients with hypertension and elevated homocysteine (Hcy) level. 2. Intensive Antihypertensive Therapy: To assess the effect of intensive antihypertensive therapy (SBP\<130 mmHg) versus standard antihypertensive therapy (SBP 130-\<140 mmHg) in reducing risk of combined cardio-cerebrovascular events in CSVD patients with hypertension and elevated Hcy level, using two basic anti-hypertensive drugs, amlodipine tablets 5 mg or amlodipine folic acid tablets 5.8 mg.
Detailed description
Hypertension is highly prevalent risk factor for stroke, particularly for stroke associated with CSVD. Blood pressure (BP) lowering has been considered an important measure for preventing stroke and progression of CSVD. Moreover, uncertainty remains regarding the efficacy of folic acid therapy for secondary prevention of stroke because of limited and inconsistent data. We propose to conduct a randomized, double-blind, placebo-controlled, multicenter, 2×2 factorial designed clinical trial to test the primary hypothesis that 1) whether amlodipine folic acid is more effective than amlodipine in reducing the risk of all-cause stroke (including fatal and non-fatal stroke) over a follow-up period among patients with CSVD. 2) whether an intensive treatment strategy (a systolic BP target of \<130mmHg) is more effective than a standard treatment strategy (a systolic BP target of 130-140mmHg) in reducing the risk of combined cardio-cerebrovascular events. Both Intention-to-treat Analysis (ITT) and Per-protocol set (PPS) were used for analysis. We will use Kaplan-Meier estimates of the cumulative risk of stroke (ischemic or hemorrhagic) event and combined cardio-cerebrovascular events during follow-up period, with hazards ratios and 95% CI calculated using Cox proportional hazards methods and the log-rank test to evaluate the treatment effect. All statistics will be 2-sided with P\<0.05 considered significant, accounting for interim analyses. All patients who received study drugs and with at least one safety follow-up record will be included in the safety population. The data for safety evaluation included adverse reactions observed during the trial and changes in laboratory data before and after treatment.
Interventions
DRUGAmlodipine folic acid 5.8mg+intensive antihypertensive therapy
Amlodipine folic acid tablet 5.8mg, taken daily, in the morning after waking. To achieve target blood pressure(SBP\<130mmHg), this study will provide, if needed, concurrent antihypertensive medications. Patients will be asked to discontinue all prior concurrent medications. Recommended treatment options are described below: 1. Add candesartan 4mg; 2. Add indapamide 2.5mg; 3. Increase dose of candesartan to 8mg; 4. Increase dose of amlodipine to 7.5mg-10mg.
DRUGAmlodipine folic acid 5.8mg+standard antihypertensive therapy
Amlodipine folic acid tablet 5.8mg, taken daily, in the morning after waking. To achieve target blood pressure (SBP:130-140mmHg), this study will provide, if needed, concurrent antihypertensive medications. Patients will be asked to discontinue all prior concurrent medications. Recommended treatment options are described below: 1. Add candesartan 4mg; 2. Add indapamide 2.5mg; 3. Increase dose of candesartan to 8mg; 4. Increase dose of amlodipine to 7.5mg-10mg.
DRUGAmlodipine+intensive antihypertensive therapy
Amlodipine tablet 5.8mg, taken daily, in the morning after waking. To achieve target blood pressure (SBP: 130-140 mmHg), this study will provide, if needed, concurrent antihypertensive medications. Patients will be asked to discontinue all prior concurrent medications. Recommended treatment options are described below: 1. Add candesartan 4mg; 2. Add indapamide 2.5mg; 3. Increase dose of candesartan to 8mg; 4. Increase dose of amlodipine to 7.5mg-10mg.
DRUGAmlodipine+standard antihypertensive therapy
Amlodipine tablet 5.8mg, taken daily, in the morning after waking. To achieve target blood pressure (SBP: 130-140 mmHg), this study will provide, if needed, concurrent antihypertensive medications. Patients will be asked to discontinue all prior concurrent medications. Recommended treatment options are described below: 1. Add candesartan 4mg; 2. Add indapamide 2.5mg; 3. Increase dose of candesartan to 8mg; 4. Increase dose of amlodipine to 7.5mg-10mg.
Sponsors
Beijing Tiantan Hospital
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
35 Years to 75 Years
Healthy volunteers
No
Inclusion criteria
1. Age 35-75 years; 2. Meets any of the following criteria: 1\) Lacunar infarction occurring within the period of seven days up to one year post-infarction, diagnosed by head MRI/CT (meeting modified Fisher criteria\*); 2）Head MRI indicating white matter hyperintensity, 4≥Fazekas score\*≥2; 3）Head MRI indicating white matter hyperintensity, Fazekas=1, combined with old subcortical vascular lacunar infarction; * For modified Fisher criteria and Fazekas score, see FAITH main study appendix 1 and appendix 6). 3\. Medical recorded history of hypertension. Systolic blood pressure SBP: 130-180 mm Hg on 0 or 1 medication SBP: 130-170 mm Hg on up to 2 medications SBP: 130-160 mm Hg on up to 3 medications. 4. mRS score ≤2; 5. Serum Hcy ≥10 µmol/L or MTHFR 677 TT genotype; 6. Signed informed consent form.
Exclusion criteria
1. Patients with secondary hypertension; 2. Symptomatic intracranial and extracranial artery stenosis (stenosis ≥50%), or asymptomatic intracranial and extracranial artery stenosis (stenosis≥70%); 3. Patients who have undergone revascularization of the heart, brain, or kidney, or other aortic stenting procedures; 4. Any symptoms of orthostatic hypotension when measuring standing blood pressure, or if standing SBP \<110mmHg; 5. Bilateral renal artery stenosis; 6. Patients who have previously taken candesartan or other angiotensin receptor antagonist (ARB) type medication, indapamide or other similar diuretic type medication, or any medication or health product containing folic acid, and reported adverse reactions; 7. Patients who have indicators for specific antihypertensive medications (e.g. β-blockers after acute myocardial infarction, RAS blockers for prevention of cardiovascular disease, α-blockers for treatment of benign prostate hyperplasia); 8. Within the last three months, regular usage of vitamin supplements containing folic acid, B6, or B12, or usage of folic acid antagonists (e.g. methotrexate); 9. Patients undergoing dialysis or with stage 4-5 chronic kidney disease, or estimated glomerular filtration rate (eGFR) \<30 mL/min/1.73m²; 10. History of epilepsy or currently using anti-epileptic medication; 11. Pregnant and lactating women, or women planning to become pregnant; 12. Life expectancy less than four years; 13. Within the last month, participation in another clinical trial; 14. Any patient determined by the researchers to be unsuitable for the present study.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| All-cause stroke (including fatal and non-fatal stroke) | 4 year after randomization | This aims to assess the effects of amlodipine folic acid tablets 5.8 mg (5 mg amlodipine + 0.8 mg folic acid)versus amlodipine tablets 5 mg in preventing stroke occurrence in cerebral small vascular disease (CSVD) patients with hypertension and elevated homocysteine (Hcy) level |
| Combined cardio-cerebrovascular events | 4 year after randomization | This aims to assess the effect of intensive antihypertensive therapy (SBP\<130 mmHg) versus standard antihypertensive therapy (SBP 130-\<140 mmHg) in reducing risk of combined cardio-cerebrovascular events in CSVD patients with hypertension and elevated Hcy level. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Ischemic stroke | 4 year after randomization | Percentage of patients within follow-up period new ischemic stroke events. |
| All-cause stroke (including fatal and non-fatal stroke) | 4 year after randomization | Secondary outcome for assessing the effect of intensive antihypertensive therapy (SBP\<130 mmHg) versus standard antihypertensive therapy (SBP 130-\<140 mmHg) in reducing risk of stroke occurrence in CSVD patients with hypertension and elevated Hcy level. |
| Hemorrhagic stroke | 4 year after randomization | Percentage of patients within follow-up period new hemorrhagic stroke events. |
| Myocardial infarction | 4 year after randomization | Percentage of patients within follow-up period new myocardial infarction events. |
| Hospitalization from heart failure | 4 year after randomization | Hospitalization, or an emergency department visit requiring treatment with infusion therapy, for a clinical syndrome that presents with multiple signs and symptoms consistent with cardiac decompensation/ inadequate cardiac pump function within follow-up period. |
| Cardio-cerebrovascular death | 4 year after randomization | Cardio-cerebrovascular death includes death caused by acute myocardial infarction (MI), sudden cardiac death, death caused by heart failure (HF), death caused by stroke, death caused by cardiovascular surgery, death caused by cardiovascular hemorrhage and other cardiovascular causes. |
| All-cause death | 4 year after randomization | This is death due to various causes, including cardiovascular and non-vascular deaths and deaths from unknown causes. |
| Combined cardio-cerebrovascular events | 4 year after randomization | Secondary outcome for assessing the effects of amlodipine folic acid tablets 5.8 mg (5 mg amlodipine + 0.8 mg folic acid)versus amlodipine tablets 5 mg in preventing combined cardio-cerebrovascular events in cerebral small vascular disease (CSVD) patients with hypertension and elevated homocysteine (Hcy) level. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Changes in score of each single item of the grading of CSVD image load | 4 year after randomization | Changes in score of each single item of the grading of CSVD image load |
| Changes in autonomic nervous system function and cerebral hemodynamics | 4 year after randomization | Changes in autonomic nervous system function and cerebral hemodynamics |
| Changes in MoCA score | 4 year after randomization | Changes in MoCA score |
| Changes in total image load score of CSVD | 4 year after randomization | Changes in total image load score of CSVD |
| Changes in WMLs and brain volume | 4 year after randomization | Changes in WMLs and brain volume |
| Malignant tumors occurence | 4 year after randomization | To assess the effects of amlodipine folic acid tablets 5.8 mg (5 mg amlodipine + 0.8 mg folic acid)versus amlodipine tablets 5 mg in preventing malignant tumors occurrence in cerebral small vascular disease (CSVD) patients with hypertension and elevated homocysteine (Hcy) level. |
Countries
China
Contacts
Primary ContactJinglin Mo
Backup ContactAnxin Wang
Outcome results
None listed