Iron Substitution With Ferric Carboxymaltose as Treatment Strategy for Heart Failure Patients With Preserved Ejection Fraction

Cantonal Hosptal, Baselland

Overview

This study aims to investigate the effects of treatment with intravenous ferric carboxymaltose on exercise tolerance measured as VO2peak in patients with HFpEF and iron deficiency, compared to placebo.

Iron deficiency is a common comorbidity associated with chronic heart failure (HF) in both, patients with preserved (HFpEF) and reduced ejection fraction (HFrEF), which has unfavorable clinical and prognostic effects. Previous studies have confirmed that HF patients with iron deficiency have a lower exercise tolerance than those without iron deficiency. In iron deficient patients with HFrEF, treatment with intravenous ferric carboxymaltose (FCM) improved symptoms, exercise tolerance and quality of life (QoL). Since the latest guidelines published by the European Society of Cardiology (ESC) in 2016, iron substitution is an official class IIa recommendation in HFrEF, while it has not yet been endorsed in the treatment guidelines for HFpEF. To date, no evidence is available on iron supplementation in HFpEF. Therefore, a clear rationale exists for examining the effects of correcting iron deficiency in this high-risk and steadily growing patient group. The proposed study will be a single-centre, prospective, double-blind, randomized, placebo-controlled trial in a primary care setting including 86 patients with stable HFpEF and iron deficiency. Participants will undergo three study visits: a baseline visit, a status control visit, and a post-intervention visit. At the baseline visit, measurements of exercise tolerance (using spiroergometry), laboratory parameters and disease-specific biomarkers (using blood samples), tHb-mass (using the carbon monoxide rebreathing method), cardiac and arterial vessel structure and function (using electrocardiogram, echocardiography and PVW), QoL (using 3 validated questionnaires), body composition (using BMI and WHR), and habitual physical activity (using a wrist-worn accelerometer) will be performed. Then, patients randomized to the treatment group will receive FCM (Vifor Pharma AG, Villars-sur-Glâne, Switzerland), whereas those in the control group will receive placebo. At week 6, iron deficiency status will be re-evaluated in all patients and, if necessary, another application of FCM or placebo will be administered, respectively. After the 12-week treatment period, the study measurements will be repeated in all patients (post-intervention visit) to investigate the effects of the intervention.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

QUADRUPLE

Conditions

Heart Failure With Normal Ejection Fraction Iron-deficiency

Interventions

Ferric carboxymaltoseDRUG

Application of FCM solution (Ferinject®, Vifor Pharma AG, Villars-sur-Glâne, Switzerland) by intravenous injection.

PlaceboDRUG

Application of placebo solution administered as normal saline (0.9% weight/volume (w/v) NaCl) by intravenous injection as per the instructions for active treatment.

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Informed consent as documented by signature * NYHA functional classes II-III * Signs and symptoms of chronic HF, such as: * Dyspnea * Paroxysmal nocturnal dyspnea * Reduced exercise tolerance * Fatigue * Extended recovery after exercising * Peripheral edema (lower leg, ankle) * EF (ejection fraction) \>50% * Structural or functional changes in echocardiography: * Left atrial volume index (LAVI) \>34 ml/m2 OR * Left ventricular mass index (LVMI) \>115 g/m2 (men), \>95 g/m2 (women) OR * E/E' (ratio between mitral peak velocity of early filling (E) to early diastolic mitral annular velocity (E')) \>13 AND mean E' septal and lateral wall \<9 cm/s * NT-proBNP \>125 pg/ml * At least 4 weeks on stable medical treatment or without signs and symptoms of cardiac decompensation * Iron deficiency defined as: * Ferritin \<100 ng/ml OR * Ferritin \<300 ng/ml with a transferrin saturation (TSAT) \<20% Exclusion Criteria: * Age \<18 years * Pregnancy or lactation * Life-expectancy \<6 months * Planned cardiac interventions in the following 6 months * Unstable angina pectoris * Uncontrolled brady- or tachyarrhythmia * Severe uncorrected valvular heart disease * Paroxysmal atrial fibrillation * Clinically significant concomitant disease states (e.g. hypertension grades 2-3 (\>160/100 mmHg), severe renal failure (GFR \<30 ml/min/1.73m2), hepatic dysfunction (ALT or AST \>3x upper limit of normal, chronic obstructive pulmonary disease (COPD) grades III-IV) * On-going cancer treatment * Significant musculoskeletal disease limiting exercise tolerance * Active infection * Immunosuppressive medical therapy * Earlier hypersensitivity to parenteral iron preparation * Anemia and iron deficiency due to active and/or chronic bleeding * Blood transfusion within the previous 30 days * Red cell, folate and vitamin B12 deficiency * Known or suspected non-compliance, drug or alcohol abuse * Inability to follow the procedures of the study, e.g. due to insufficient language skills, psychological disorders, dementia, etc. * Participation in another intervention study * Enrolment of the investigators, their family members, and other persons involved in the study procedures * Hemoglobin \< 120 ng/ml in male patients or \< 110 ng/ml in female patients

Outcomes

Primary Outcomes

Change in peak oxygen uptake (VO2peak)

Change of VO2peak will be measured by spiroergometry at the baseline and post-intervention visit.

Time frame: 12 weeks

Secondary Outcomes

Change in ventriculo-arterial coupling (VAC)

VAC is defined as the ratio of arterial elastance (Ea) and end-systolic elastance (Ees) and will be approximated echocardiographically based on the method described by Antonini-Canterin et al.

Time frame: 12 weeks

Change in arteriovenous oxygen difference (Da-vO2)

Da-vO2 will be calculated using the Fick Principle

Time frame: 12 weeks

Change in pulse wave velocity (PWV)

PWV will be measured at the same time as the echocardiographic parameters with the VaSera VS-2000 Vascular Screening System (Fukuda Denshi Co. Ltd, Tokyo, Japan) and evaluated by experienced blinded members of the study team.

Time frame: 12 weeks

Change in New York Heart Association (NYHA) functional class

NYHA functional class will be determined according to the New York Heart Association classification.

Time frame: 12 weeks

Change in habitual physical activity

Habitual physical activity will be measured by an accelerometer over a period of 14 consecutive days for 24 hours per day following baseline and post-intervention visits. Patients will wear a waterproof micro-electromechanical triaxial activity bracelet on the non-dominant wrist (GeneActiv, Activinsights Ltd, Kimbolton, Cambridgeshire, UK) to assess physical activity intensity (light, moderate, vigorous) and periods of inactivity, sleep and wake.

Time frame: 12 weeks

Data from ClinicalTrials.gov

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