The mainstay treatment for reducing the symptoms of angina and long-term risk of heart attacks in patients with heart disease is stent implantation in the diseased coronary artery. Whilst this procedure has revolutionised treatment the incidence of secondary events remains a concern. These repeat events are due in part to continued enhanced platelet reactivity, endothelial dysfunction and a phenomenon called 'restenosis' i.e. the stent becomes blocked ultimately requiring another expensive and risky procedure. In this study it will be determined whether a once daily inorganic nitrate administration might favourably modulate platelet reactivity and endothelial function leading to a decrease in restenosis.
To address the aims a proof-of-concept study will be conducted to ascertain whether a dietary nitrate approach might prove useful adjunctive therapy improving vascular function in patients with stable angina post elective angioplasty. Design: A prospective randomised, single-centre, double-blind, placebo-controlled trial Setting: Patients with stable angina and single/multiple coronary artery stenosis undergoing elective percutaneous coronary intervention (PCI) who are haemodynamically stable (systolic BP\>100 mmHg). These patients will be recruited at The Barts Health Heart Centre, based at St. Bartholomew's Hospital. This is one of the biggest centres in the United Kingdom, serving a population of almost two million people from The City of London and The North East up to the M25 and is a 24/7 centre performing approximately 2000 non-primary angioplasties a year. The study will take place in the Clinical Trials Unit, William Harvey Heart Centre. Target population: A total of 300 patients (male and female, age 18-85) with stable angina as per requirements indicated above. Follow-up will take place in the Clinical Trials Unit, William Harvey Research Institute. Treatment: Patients will be randomised (using an on line randomisation database) to receive 70 ml of a beetroot juice concentrate containing 4-5 mmol nitrate or nitrate-deplete placebo juice concentrate. This intervention will be taken by the patient daily from one day prior to re-establishment of flow with PCI and stent implantation. Analysis: We will analyse the results based on an intention to treat analysis. We will also carry out further per protocol analyses and a subgroup analysis on patients who are on organic nitrates as part of their routine therapy and a comparison of DES (drug-eluting stents) versus BMS (bare-metal stents).
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
QUADRUPLE
Enrollment
300
70 ml of beetroot juice containing \~5 mmol of inorganic nitrate
70 ml of beetroot juice which is nitrate-depleted
William Harvey Research Institute, Barts and The London School of Medicine
London, United Kingdom
Difference between groups in In-stent late loss, where late loss is defined as the difference between the minimum luminal diameter (MLD).
Time frame: 6 months +/- 1 month post intervention
Difference from baseline within the group and between groups in endothelial function assessed by flow-mediated dilatation of the brachial artery at 6 months compared to pre-procedure assessment.
Time frame: 6 months and 12 months post intervention
Difference from baseline within the group and between groups in target vessel revascularisation (TVR).
Time frame: 6 months post intervention
Difference from baseline within the group and between groups in restenosis rate (diameter >50%).
Time frame: 6 months post intervention
Difference from baseline within the group and between groups in in-segment late loss.
Time frame: 6 months post intervention
Difference from baseline between groups in major adverse cardiac events (i.e. Myocardial Infarction, death, Cerebrovascular Accident, Target Vascular Revascularisation).
Time frame: 6 months, 12 months and 24 months post intervention
Difference from baseline within the group and between groups in inflammatory markers.
Time frame: 6 months and 12 months post intervention
Difference from baseline within the group and between groups in plasma and erythrocyte nitrite reductase.
Time frame: 6 months and 12 months post intervention
Difference from baseline within the group and between groups in changes in plasma xanthine oxidase activity.
Time frame: 6 months and 12 months post intervention
Difference from baseline within the group and between groups high-sensitivity C-reactive protein (hsCRP).
Time frame: 6 months and 12 months post intervention
Difference from baseline within the group and between groups in Interleukin-6 (IL-6).
Time frame: 6 months and 12 months post intervention
Difference from baseline within the group and between groups in platelet activation (P-Selectin and platelet-monocyte aggregates).
Time frame: 6 months and 12 months post intervention
Difference from baseline within the group and between groups in platelet aggregation ex vivo (ADP, collagen, arachidonic acid).
Time frame: 6 months and 12 months post intervention
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