Heart Failure With Preserved Ejection Fraction (HFPEF), Coronary Artery Disease
Conditions
Keywords
HFpEF, Heart failure with preserved ejection fraction, REPRIEVED, REPRIEVED trial, Placebo PCI, CAD
Brief summary
HFpEF (heart failure with preserved ejection fraction) is a condition in which the heart muscle becomes stiff and can't pump blood properly. People living with HFpEF also often have coronary artery disease, where the blood vessels that supply the heart are narrowed or blocked. It is not yet know whether opening these arteries with stents improves symptoms or quality of life with HFpEF. REPRIEVED is a randomised clinical trial that aims to find out if heart stents can improve quality of life for people living with heart failure with preserved ejection fraction (HFpEF) and coronary artery disease. Researchers will compare two groups of people; those who have a stent procedure to those who have a placebo procedure. The placebo procedure feels the same as a stent procedure but does not include a stent. 350 people with HFpEF and coronary artery disease will be asked to take part. Participants will be monitored over a period of 6 months to see if and how quality of life changes. Before the procedure, participants will be asked to complete a short health questionnaire, have a blood test, undergo an electrocardiogram (heart tracing) and scans of their heart. On the day of the procedure, the participant will come to the hospital for an angiogram and will be randomly allocated to have either treatment with a stent or the placebo procedure without a stent. Participants will not know whether they have received heart stents. This helps researchers know that any improvements in their quality of life are not just related to how they feel about the stenting treatment. Participants will then be contacted by a member of the research team at 3 months and 6 months after their procedure. At 3 months, participants will complete a short health questionnaire either by phone or during a hospital visit. At 6 months, participants will attend the hospital to complete a short health questionnaire, have blood tests, a scan of the heart (echocardiogram) and an electrocardiogram (heart tracing) to measure any changes in the heart. Participants will be told whether they received the stent procedure or the placebo procedure.
Interventions
PROCEDUREPercutaneous coronary intervention
Participants will receive percutaneous coronary intervention (PCI) as per current standard of care. Angioplasty and stenting will be attempted to all significant coronary stenoses as determined by the CT-FFR or FFR measurements. Contemporary best practice including the use of intracoronary imaging is mandated. The default approach will be to implant drug eluting stents, but drug coated balloon angioplasty is permitted in selected cases in accordance with the current evidence base and guidelines. Operators will achieve as much revascularisation as can safely be delivered in a timeframe which maintains blinding; if incomplete revascularisation is necessary, operators will target treatment to the most haemodynamically significant lesions subtending the largest territories. Staged procedures are not permitted.
OTHERPlacebo procedure
Participant will undergo a placebo PCI procedure that involves placement of a thin tube to image the blood vessel but does not involve placement of an actual stent. Movements of the image intensifier, screen display and personnel will simulate a PCI procedure.
Sponsors
King's College London
Guy's and St Thomas' NHS Foundation Trust
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
DOUBLE (Subject, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1\. A diagnosis of HFpEF, defined by the European Society of Cardiology (ESC) criteria, defined as: 1. Symptoms of heart failure (New York Heart Association (NYHA) class II-IV) and 2. Left ventricular ejection fraction ≥ 50% and 3. NT-pro-BNP \> 125 pg/ml in sinus rhythm or \> 365 pg/ml in atrial fibrillation and 4. One or more of the following objective signs of left ventricular diastolic dysfunction: i. Invasively measured left ventricular end diastolic pressure ≥ 15 mmHg at rest or ≥ 25 mmHg on exercise (directly measured or estimated via pulmonary capillary wedge pressure) ii. Estimated pulmonary artery systolic pressure \> 35mmHg or tricuspid regurgitation velocity \> 2.8 m/s on echocardiography iii. Left atrial volume index \> 34ml/m2 in patient in sinus rhythm or left atrial volume index \> 40ml/m2 in atrial fibrillation iv. Relative left ventricular wall thickness \> 0.42 v. Left ventricular mass index ≥ 95 g/m2 in females or ≥ 115 g/m2 in males vi. Mitral E/E' ratio \> 9
Exclusion criteria
1. Age \<18 years 2. People without capacity to provide informed consent 3. PCI contraindicated or not feasible on coronary angiography or screening CTCA 4. Contraindication to clopidogrel/dual antiplatelet therapy 5. Recent acute myocardial infarction or coronary revascularisation (within 90 days) 6. Enrolment in another interventional study which may affect study outcomes 7. Severe chronic obstructive pulmonary disease (GOLD stage ≥3) 8. Haemoglobin \<=80 g/L 9. Other cardiac diagnosis as a cause for HFpEF (hypertrophic cardiomyopathy, untreated severe left sided valvular disease, cardiac amyloidosis)
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Quality of life measured using KCCQ-OSS | At 6 months |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| All-cause death and hospitalisation for heart failure | At 6 months | — |
| Efficacy of blinding assessed using the blinding index | At discharge from the procedure | The blinding index is scaled to an interval of -1 to 1, 1 being complete lack of blinding, 0 being consistent with perfect blinding and -1 indicating opposite guessing which may be related to unblinding. |
| Individual components of the KCCQ (including total symptom score and clinical summary score) | At 6 months | — |
| Health status measured using New York Heart Association (NYHA) functional class | At 6 months | — |
| NT-pro-BNP measured using blood test/assay | At 6 months | — |
| Difference in left ventricular ejection fraction (LVEF) | At 6 months | — |
| Difference in diastolic function (mitral E/e') | At 6 months | — |
Countries
United Kingdom
Outcome results
None listed