Early Mineralocorticoid Receptor Antagonist Treatment to Reduce Myocardial Infarct Size

Overview

Heart attacks, or myocardial infarcts, are a major cause of death and disability in the UK. Immediate unblocking of the obstructed heart vessel with a balloon catheter and implantation of a mesh scaffold (stent) in heart centers is warranted in these patients. Morbidity and mortality in this patient group is related to the infarct size. Therefore, there is a need to discover novel therapeutic agents which reduce myocardial infarct size and preserve the contractile heart function. Large trials involving several thousand patients have demonstrated a survival benefit in patients with impaired heart function due to a heart attack, who received a mineralo-corticoid receptor antagonist (MRA, drug name: spironolactone). In these trials patients received the drug late, 3-14 days after the heart attack. Our proposal is to investigate whether MRA therapy administered intravenously prior to unblocking an occluded heart vessel, can reduce infarct size and as such can prevent long term sequelae of heart attacks. 150 patients admitted to 4 tertiary care hospitals (Heart Hospital London, London Chest, Essex Cardiothoracic Center and Leeds General Infirmary) for heart attack will be randomly assigned to receive MRA treatment or placebo. The first dose of the MRA will be applied intravenously immediately in the catheter suite, even before re-opening of the occluded vessel. From the second day on, patients will be prescribed oral MRA treatment, as a pill, for a total of three months. Before hospital discharge and after three months, a magnetic resonance image (MRI) of the heart will accurately investigate the evolution of infarct (scar) size and the contractile heart function and compare the group of patients who received the MRA drug versus the placebo control group. Of note, patients with an ejection fraction <40% AND signs of heart failure OR diabetes will go on open label eplerenone according to current guidelines, instead of the study drug. This study will give first evidence, if very early MRA treatment improves heart function and should be used as early as possible for treatment of patients after a heart attack.

Full Title of Study: “MINeralocorticoid Receptor Antagonist Pretreatment to MINIMISE Reperfusion Injury After ST-Elevation Myocardial Infarction (STEMI)”

Study Type

• Study Type: Interventional
• Study Design
  • Allocation: Randomized
  • Intervention Model: Parallel Assignment
  • Primary Purpose: Treatment
  • Masking: Triple (Participant, Investigator, Outcomes Assessor)
• Study Primary Completion Date: May 2016

Interventions

• Drug: Mineralocorticoid receptor antagonist potassium-canrenoate
• Drug: placebo

Arms, Groups and Cohorts

• Placebo Comparator: Placebo
  • Intravenous saline bolus prior to PPCI followed by oral placebo for 3 months
• Active Comparator: Mineralocorticoid receptor antagonist
  • 1st dose (day 0) given i.v. (potassium-canrenoate), before primary PCI day 1 – 12 weeks: spironolactone 25mg daily, which is uptitrated to 50mg daily after 2 weeks, if possible In case the LVEF <40% on baseline MRI and the patient shows signs of heart failure or is diabetic, the patient will receive open label eplerenone instead of the study drug, according to current guidelines.

Clinical Trial Outcome Measures

Primary Measures

• Myocardial infarct (MI) size, as assessed by cardiac magnetic resonance imaging
  • Time Frame: 12 weeks after STEMI

Secondary Measures

• Markers of myocardial reperfusion injury
  • Time Frame: 48 hours
  • TIMI flow post-PPCI, ST-segment resolution post-PPCI
• Microvascular obstruction on cardiac MRI
  • Time Frame: 1-3 days after STEMI
  • hypodense area of late gadolinium enhancement
• Myocardial salvage
  • Time Frame: 12 weeks
  • Area at risk assessed by T2 weighted imaging subtract final MI size
• Acute myocardial infarct size
  • Time Frame: 1-3 days
  • serum biomarkers: hsTnT, CK-MB, CK and cardiac MRI: late gadolinium enhancement
• LV remodelling
  • Time Frame: 12 week cardiac MRI scan
  • LV end-diastolic and end-systolic volumes, LV ejection fraction, LV mass and wall-thickness
• Clinical outcome measures
  • Time Frame: 12 weeks
  • cardiovascular death, non-fatal myocardial infarction, revascularisation, hospitalisation for heart failure, hyperkalemia, deterioration of kidney function, need for dialysis

Participating in This Clinical Trial

Inclusion Criteria

Inclusion criteria for entry into trial

• Patients >18 years – Patients presenting with acute STEMI (as assessed by 12 lead ECG; ST segment elevation ≥2 mm (0.2 mV) in 2 or more contiguous precordial leads or ≥1mm (0.1mm) in 2 or more adjacent limb leads). – Presentation within 12 hours after symptom onset Inclusion criteria for randomization (assessed in catheter laboratory) – Angiographically proven proximal occlusion (TIMI 0) of a major coronary vessel (LAD, LCX, RCA). – Normal potassium (<5.0 mmol/l) Exclusion Criteria:

• Patients with known LVEF ≤40% – Participation in another trial – Cardiogenic shock (positive shock index OR need for catecholamine support OR systolic blood pressure < 90 mmHg) – Killip class > 2 – Prior myocardial infarction – Known compromised renal function (eGFR < 30 ml/min/1.73 m2) or potassium > 5.0 mmol/l – Current treatment with mineralocorticoid receptor antagonists – Pregnant or lactating females – Allergies to IMP or its excipients – Known contraindication to cardiac magnetic resonance imaging (MRI) such as significant claustrophobia, severe allergy to gadolinium chelate contrast, , presence of MRI contraindicated implanted devices (eg, pacemaker, implanted cardiac defibrillator, cardiac resynchronization therapy device, cochlear implant), imbedded metal objects (eg, shrapnel), or any other contraindication for cardiac MRI.

Gender Eligibility: All

Minimum Age: 18 Years

Maximum Age: N/A

Are Healthy Volunteers Accepted: No

Investigator Details

• Lead Sponsor
  • University College, London
• Collaborator
  • British Heart Foundation
• Provider of Information About this Clinical Study
  • Sponsor
• Overall Official(s)
  • Derek J Hausenloy, PhD, Study Director, University College London, Hatter Cardiovascular Institute
  • Georg M Fröhlich, MD, Study Chair, University College London, The Heart Hospital
  • Pascal Meier, MD, Principal Investigator, University College London, The Heart Hospital
  • Reto Gamma, MD, Principal Investigator, Basildon and Thurrock University Hospitals
  • Anthony Mathur, PhD, Principal Investigator, London Chest Hospital
  • John Greenwood, MD, Principal Investigator, Leeds General Infirmary

References

Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M; Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 2003 Apr 3;348(14):1309-21. doi: 10.1056/NEJMoa030207. Epub 2003 Mar 31. Erratum In: N Engl J Med. 2003 May 29;348(22):2271.

Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H, Vincent J, Pocock SJ, Pitt B; EMPHASIS-HF Study Group. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med. 2011 Jan 6;364(1):11-21. doi: 10.1056/NEJMoa1009492. Epub 2010 Nov 14.

Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, Palensky J, Wittes J. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med. 1999 Sep 2;341(10):709-17. doi: 10.1056/NEJM199909023411001.

Schmidt K, Tissier R, Ghaleh B, Drogies T, Felix SB, Krieg T. Cardioprotective effects of mineralocorticoid receptor antagonists at reperfusion. Eur Heart J. 2010 Jul;31(13):1655-62. doi: 10.1093/eurheartj/ehp555. Epub 2009 Dec 21.