Comparing Immune System Suppression to Medication for Unexplained Heart Function and Irregular Heartbeat

Official title

Immunosuppression Versus Medical Therapy for UN-explained Low Ejection Fraction and VT

Overview

Ventricular tachycardia (VT, a potentially fatal condition where the ventricle of the heart beats rapidly) superimposed on non-ischemic cardiomyopathy (NICM, a disease of heart with broad etiologies except coronary artery disease). This disease has been associated with inflammation in the heart. The purpose of this study is to assess the benefit of immunosuppressive therapy to suppress the VT, improve heart function, avoid invasive intervention and hospitalization. Positron Emission Tomography (PET) imaging shows inflammation in the heart. After enrollment, baseline tests (including physical exams, blood tests, genetic test, electrocardiography, echocardiography) will be done. Next, will be an 8-week medication regimen which contains either immunosuppressive drugs or standard GDMT without immunosuppressant medication. Some of the examinations will be repeated during the study to evaluate the treatment response and monitor any adverse events.

Detailed description

Ventricular arrhythmia (VT) is a well-established consequence in patients with non-ischemic cardiomyopathy (NICM). NICM is a broad category that includes a wide spectrum of causes, which may include: bacterial, viral toxin mediated and immune mediated and "unexplained" when coronary disease has been excluded. The pathophysiology of NICM is not well understood but inflammatory responses with macrophage recruitment during remodeling have been described. On the other hand, an infectious trigger i.e. myocarditis may be the inciting event for the development of cardiomyopathy. A previous study by Tung et al showed that nearly 50% of patients with unexplained cardiomyopathy and ventricular arrhythmias presented ongoing focal myocardial inflammation on PET. To date, targeting inflammation as a substrate in order to reduce burden of ventricular tachycardia has not been investigated in randomized prospective fashion.

The TIMIC trial was one of the few randomized studies to examine long-term benefit of immunosuppressive therapies in patients with virus-negative NICM. A moderate improvement in Left Ventricular Ejection Fraction (LVEF) over 6 months after initiation of immunosuppressive therapy was demonstrated in this study but current guidelines do not routinely recommend anti-inflammatory therapies for NICM. While considered to be gold standard, endomyocardial biopsy can often times be incorrect due to sampling error and typically is not performed multiple times in patient with chronic non-ischemic cardiomyopathy. Fasting Fluorodeoxyglucose (FDG)-positron emission tomography (PET) is an emerging imaging modality to identify and monitor abnormal metabolic patterns of the myocardium. By exploiting the metabolic demand of inflammatory tissue with macrophage recruitment, PET imaging is emerging as the preferred modality to diagnose and measure response to therapy for patients with myocarditis and sarcoidosis. A recent study by Kandolin et al in Finland showed that the incidence of cardiac sarcoidosis has increased by 20-fold over the past two decades.

FDG-PET may reveal inflammation as a central pathophysiologic mechanism in a significant proportion of patients with unexplained cardiomyopathy and VT. Potential innovative insights from the trial will be to identify the underlying pathogenesis of idiopathic cardiomyopathy and assess whether immunosuppression changes the clinical course of patients with identified arrhythmogenic cardiomyopathy. Aside from guideline-direct medical therapy (GDMT), antiarrhythmic agents, and catheter ablation, there are no disease-specific therapies for patients with VT and NICM. Prospective studies that evaluate the incidence of occult inflammation and clinical response to anti-inflammatory and immunosuppressive therapy have not been performed to date and are warranted for the emerging NICM population referred for advanced heart failure and arrhythmia management.

Interventions

• Drug Prednisone 40mg
  Prednisone 40mg x 8weeks

Primary outcome measures

• Burden of ventricular arrhythmias [Time frame: 12 months (8 weeks and 6 months)]
• Change in left ventricular ejection fraction (LVEF) [Time frame: 12 months (8 weeks and 6 months)]
• Change in QRS duration [Time frame: 12 months (8 weeks and 6 months)]
• Change in FDG (18F-fluorodeoxyglucose) uptake [Time frame: 12 months]

Secondary outcome measures (4)

• Cardiovascular hospitalization [Time frame: 6 months and 12 months.]
• Need for catheter ablation [Time frame: 6 months and 12 months.]
• NYHA functional class [Time frame: 6 months and 12 months]
• Survival [Time frame: 6 months and 12 months]

Eligibility criteria

Inclusion criteria

• 18 years of age, all races, all gender
• LV systolic function \< 50%
• Optimized GDMT Per physicians' discretion (SOC treatment)
• No evidence of ischemic cardiomyopathy
• No evidence of obstructive coronary disease
• Viral panel negative
• NYHA class II, III and ambulatory class IV heart failure
• History of VA (documentation of Sustained VT last more than 30 seconds)
• Heart inflammation confirmed by PET scan
• Steroid use within 12 months prior to of date of consent

Exclusion criteria

• Life expectancy less than 24 months
• Pregnancy
• Contra indications or intolerance of prednisone or any excipients in the formulation
• Hypothalamic-pituitary-adrenal axis suppression, Cushing's syndrome, active infection, glaucoma or any other pathology where corticosteroids are not recommended.
• Any patient with HIV, low white blood cells, and chronic infection (active fungal, TB, Valley fever)

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Open label

Primary purpose

Treatment

Study locations

United States · 1 center

• Banner - University Medical Center, Phoenix campus — Phoenix

Publications

• Tung R, Bauer B, Schelbert H, Lynch JP 3rd, Auerbach M, Gupta P, Schiepers C, Chan S, Ferris J, Barrio M, Ajijola O, Bradfield J, Shivkumar K. Incidence of abnormal positron emission tomography in patients with unexplained cardiomyopathy and ventricular arrhythmias: The potential role of occult inflammation in arrhythmogenesis. Heart Rhythm. 2015 Dec;12(12):2488-98. doi: 10.1016/j.hrthm.2015.08.01 PMID 26272522
• Belperio JA, Shaikh F, Abtin FG, Fishbein MC, Weigt SS, Saggar R, Lynch JP 3rd. Diagnosis and Treatment of Pulmonary Sarcoidosis: A Review. JAMA. 2022 Mar 1;327(9):856-867. doi: 10.1001/jama.2022.1570. PMID 35230389
• Rahaghi FF, Baughman RP, Saketkoo LA, Sweiss NJ, Barney JB, Birring SS, Costabel U, Crouser ED, Drent M, Gerke AK, Grutters JC, Hamzeh NY, Huizar I, Ennis James W 4th, Kalra S, Kullberg S, Li H, Lower EE, Maier LA, Mirsaeidi M, Muller-Quernheim J, Carmona Porquera EM, Samavati L, Valeyre D, Scholand MB. Delphi consensus recommendations for a treatment algorithm in pulmonary sarcoidosis. Eur Respir PMID 32198218
• Melani AS, Bigliazzi C, Cimmino FA, Bergantini L, Bargagli E. A Comprehensive Review of Sarcoidosis Treatment for Pulmonologists. Pulm Ther. 2021 Dec;7(2):325-344. doi: 10.1007/s41030-021-00160-x. Epub 2021 Jun 18. PMID 34143362
• Kandolin R, Lehtonen J, Airaksinen J, Vihinen T, Miettinen H, Ylitalo K, Kaikkonen K, Tuohinen S, Haataja P, Kerola T, Kokkonen J, Pelkonen M, Pietila-Effati P, Utrianen S, Kupari M. Cardiac sarcoidosis: epidemiology, characteristics, and outcome over 25 years in a nationwide study. Circulation. 2015 Feb 17;131(7):624-32. doi: 10.1161/CIRCULATIONAHA.114.011522. Epub 2014 Dec 19. PMID 25527698
• Ishimaru S, Tsujino I, Takei T, Tsukamoto E, Sakaue S, Kamigaki M, Ito N, Ohira H, Ikeda D, Tamaki N, Nishimura M. Focal uptake on 18F-fluoro-2-deoxyglucose positron emission tomography images indicates cardiac involvement of sarcoidosis. Eur Heart J. 2005 Aug;26(15):1538-43. doi: 10.1093/eurheartj/ehi180. Epub 2005 Apr 4. PMID 15809286
• Chareonthaitawee P, Beanlands RS, Chen W, Dorbala S, Miller EJ, Murthy VL, Birnie DH, Chen ES, Cooper LT, Tung RH, White ES, Borges-Neto S, Di Carli MF, Gropler RJ, Ruddy TD, Schindler TH, Blankstein R; EXPERT CONTENT REVIEWERS. Joint SNMMI-ASNC Expert Consensus Document on the Role of 18F-FDG PET/CT in Cardiac Sarcoid Detection and Therapy Monitoring. J Nucl Med. 2017 Aug;58(8):1341-1353. doi: 10 PMID 28765228
• Kebed KY, Carter SV, Flatley E, Ward RP, Moss JD, Appelbaum DE, Singh A, Lang RM, Tung R, Patel AR. Prevalence of newly diagnosed sarcoidosis in patients with ventricular arrhythmias: a cardiac magnetic resonance and 18F-FDG cardiac PET study. Int J Cardiovasc Imaging. 2021 Apr;37(4):1361-1369. doi: 10.1007/s10554-020-02090-2. Epub 2020 Nov 22. PMID 33225427

Identifiers

NCT: NCT06635863 · STUDY00003729

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗