Heart Failure Preserved Ejection Fraction, Resistant Hypertension
Conditions
Keywords
Hypertension, Xanthine Oxidase, African American, Black, Heart Failure
Brief summary
African American adults in the United States have the highest prevalence rate of high blood pressure (hypertension) and heart failure in the world. African Americans with treatment resistant hypertension have higher levels of the enzyme - xanthine oxidase compared to Caucasians. This trial will test if administration of the xanthine oxidase inhibitor - Allopurinol (commonly used in the treatment of gout), given over a period of 8 weeks, will improve heart function, exercise ability and quality of life in African American Veterans with resistant hypertension.
Detailed description
Hypertension among African American adults in the United States has one of the highest prevalence rates in the world and is related to adverse changes in left ventricular (LV) structure and function. Hypertension is an underlying factor in greater than 50% of African American adults with heart failure and is the strongest risk factor in that population. African American adults have a 50% increased incidence of heart failure, due in large part due to the greater prevalence and severity of hypertension. Heart failure occurs 8 years earlier in African American adults compared with Caucasians. Further, African American adults with heart failure have worse quality of life and depressive symptoms and have a 5-year mortality rate that is 34% higher than in Caucasians. Although African American adults have the highest death rate for heart failure, they are consistently under-represented in clinical trials. The greater heart failure burden among African Americans calls for further work to discover effective preventive and therapeutic strategies for this higher-risk population with heart failure preserved ejection fraction (HFpEF). An estimated 10-20% of hypertensive patients have resistant hypertension (RHTN), defined as having controlled or uncontrolled blood pressure with the use of 3 or more medications that includes a diuretic. A recent study reported increased plasma xanthine oxidase (XO) activity and mitochondrial DNA damage associated molecular products (mtDAMPs) levels in African American adults with RHTN, compared with Caucasian adults with RHTN. This supports the consensus that oxidative stress is higher in African American adults. Increased xanthine oxidase in heart muscle cells causes a breakdown of muscle structure and a decrease in calcium sensitivity, resulting in left ventricular (LV) dysfunction. A recent study shows that diastolic blood pressure, and other indices of LV diastolic function positively relate to xanthine oxidase activity among African American but not Caucasian RHTN patients. Given the higher level of xanthine oxidase activity and mtDAMPs in African Americans, the purpose of this clinical trial is to test whether blockade with Allopurinol (for 8 weeks) will improve LV diastolic function, exercise capacity and quality of life metrics in 50 African American Veterans with resistant hypertension.
Interventions
DRUGAllopurinol
Single arm of Allopurinol treatment for 300mg/daily for 4 weeks then may be increased to 600mg/daily for an additional 4 weeks.
Sponsors
VA Office of Research and Development
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Intervention model description
This is an open label unblinded drug pilot study to determine whether Allopurinol improves left ventricular diastolic function, exercise capacity, and quality of life in African American Veterans with resistant hypertension after 8-weeks of treatment.
Eligibility
Sex/Gender
ALL
Age
18 Years to 75 Years
Healthy volunteers
No
Inclusion criteria
In order to be eligible to participate in this study, an individual must meet all of the following criteria: 1. Veteran 2. African American 3. Resistant hypertension diagnosis (defined as blood pressure greater than 140/90 millimeters of mercury (mmHg) at 2 clinic visits despite the use of 3 antihypertensive medications at pharmacologically effective doses) 4. Locale - Birmingham, AL and surrounding areas
Exclusion criteria
1. History of heart failure 2. Chronic kidney disease (estimated creatinine clearance \< 60 milliliters per minute (ml/min) 3. Chronic steroid therapy 4. Known coronary artery disease 5. Known causes of secondary hypertension 6. Already taking Allopurinol Magnetic Resonance Imaging Exclusion 1. Claustrophobia 2. Cardiac implantable electronic device (permanent pacemaker and/or intracardiac defibrillator) 3. Metal clips and/devices or other item that specifically prohibit safe cardiovascular magnetic resonance imaging (CMR)
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Left ventricular (LV) end-diastolic mid-wall radius to wall thickness ratio | 8 weeks | Change from baseline in left ventricular diastolic function index: LV end-diastolic mid-wall radius to wall thickness ratio. Ratio (no units; Range: 1.5-4.0). |
| Self reported Health Survey | 8 weeks | Change in self reported quality of life measures using the Quality of Life Medical Outcomes Study Questionnaire (SF 36 QOL) after 8-weeks of Allopurinol. Scale (Minimum - 0; Maximum - 100; High score = worse outcome) |
| Left ventricular end-diastolic volume index | 8 weeks | Change from baseline in left ventricular diastolic function index: left ventricular end diastolic volume normalized to body surface area after 8-weeks of treatment with Allopurinol. (Range 40 - 100 milliliters per square meter (mL/m2) |
| Left ventricular (LV) end-diastolic mass index | 8 weeks | Change from baseline in left ventricular diastolic function index: LV end-diastolic mass indexed to body surface area after 8-weeks of treatment with Allopurinol. (Range: 40-100 grams/square meter (m2) |
| Left ventricular (LV) end-diastolic fractional shortening | 8 weeks | Change from baseline in left ventricular diastolic function index: LV end-diastolic fractional shortening after 8-weeks of treatment with Allopurinol. (Range: 15-80%) |
| Normalized peak late diastolic filling rate (A), EDV/s | 8 weeks | Change from baseline in left ventricular diastolic function index: Normalized peak late diastolic filling rate (A) after 8-weeks of treatment with Allopurinol. (Range 1.3 - 4.5 end-diastolic velocity (EDV)/second) |
| Normalized peak early diastolic filling rate (E) | 8 weeks | Change from baseline in left ventricular diastolic function index: Normalized peak early diastolic filling rate (E) after 8-weeks of treatment with Allopurinol. (Range 1.5 - 3.0 end-diastolic velocity (EDV)/second) |
| Six minute walk test | 8 weeks | Change in exercise capacity by six minute walk test after 8-weeks of Allopurinol. Timed activity for distance walked (Distance range approximately 400-800 meters (m); Further distance = better outcome) |
| Self Reported health survey for Heart Failure | 8 weeks | Change in self reported quality of life measures using Kansas City Heart Failure Questionnaire (KCCQ-12) after 8-weeks of Allopurinol. Scale (Minimum - 0 ; Maximum - 100; High score = worse outcome) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Systolic Blood Pressure | 8 weeks | Change in systolic blood pressure after 8 weeks of Allopurinol. Range: 120-200 millimeters of mercury (mmHg) |
| Xanthine Oxidase | 8 weeks | Change in systemic levels of xanthine oxidase (range - Xanthine oxidase activity, U/mg protein - Range 0 - 0.1) |
| mitochondrial DNA damage-associated molecular patterns | 8 weeks | Change in systemic levels of mitochondrial DNA damage-associated molecular patterns (range 0-5000 copies/uL) |
| Brain Natriuretic Peptide | 8 weeks | Change in systemic levels of brain natriuretic peptide (BNP) after 8 weeks of Allopurinol (Scale 0 to \> 100 pgmL; Minimum 0; Maximum \>100). |
| Diastolic Blood Pressure | 8 weeks | Change in diastolic blood pressure after 8 weeks of Allopurinol. Range: 70-110 millimeters of mercury (mmHg) |
Countries
United States
Contacts
PRINCIPAL_INVESTIGATORLouis J Dell'Italia, MD
Birmingham VA Medical Center, Birmingham, AL
Outcome results
None listed