Effect of Inorganic Nitrite vs Placebo on Exercise Capacity Among Patients With Heart Failure With Preserved Ejection Fraction The INDIE-HFpEF Randomized Clinical Trial

• Authors: Barry A. Borlaug, Mayo Clinic; Kevin J. Anstrom, Duke University; Gregory D. Lewis, Harvard Medical School; Sanjiv J. Shah, Northwestern University; James A. Levine, Mayo Clinic; Gabe A. Koepp, Mayo Clinic; Michael M. Givertz, Harvard Medical School; G. Michael Felker, Duke University; Martin M. LeWinter, University of Vermont; Douglas L. Mann, Washington University; Kenneth B. Margulies, University of Pennsylvania; Andrew L Smith, Emory University; W. H.Wilson Tang, Cleveland Clinic; David J. Whellan, Thomas Jefferson University; Horng H. Chen, Mayo Clinic; Victor G. Davila-Roman, Washington University; Steven McNulty, Duke University; Patrice Desvigne-Nickens, National Heart, Lung, and Blood Institute; Adrian F. Hernandez, Duke University; Eugene Braunwald, Harvard Medical School; Margeret M. Redfield, Mayo Clinic
• Journal Title: Journal of the American Medical Association
• Volume: Volume 320, Number 17
• Publisher: American Medical Association (AMA): JAMA | 2018-11-06, Pages 1764-1773
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.1001/jama.2018.14852
• Subjects: Health Sciences, Medicine and Surgery
• Keywords: Science & Technology; Life Sciences & Biomedicine; Medicine, General & Internal; General & Internal Medicine; HEMODYNAMICS; NITRATE; COMORBIDITIES

Abstract

Importance: There are few effective treatments for heart failure with preserved ejection fraction (HFpEF). Short-term administration of inorganic nitrite or nitrate preparations has been shown to enhance nitric oxide signaling, which may improve aerobic capacity in HFpEF. Objective: To determine the effect of 4 weeks' administration of inhaled, nebulized inorganic nitrite on exercise capacity in HFpEF. Design, Setting, and Participants: Multicenter, double-blind, placebo-controlled, 2-treatment, crossover trial of 105 patients with HFpEF. Participants were enrolled from July 22, 2016, to September 12, 2017, at 17 US sites, with final date of follow-up of January 2, 2018. Interventions: Inorganic nitrite or placebo administered via micronebulizer device. During each 6-week phase of the crossover study, participants received no study drug for 2 weeks (baseline/washout) followed by study drug (nitrite or placebo) at 46 mg 3 times a day for 1 week followed by 80 mg 3 times a day for 3 weeks. Main Outcomes and Measures: The primary end point was peak oxygen consumption (mL/kg/min). Secondary end points included daily activity levels assessed by accelerometry, health status as assessed by the Kansas City Cardiomyopathy Questionnaire (score range, 0-100, with higher scores reflecting better quality of life), functional class, cardiac filling pressures assessed by echocardiography, N-terminal fragment of the prohormone brain natriuretic peptide levels, other exercise indices, adverse events, and tolerability. Outcomes were assessed after treatment for 4 weeks. Results: Among 105 patients who were randomized (median age, 68 years; 56% women), 98 (93%) completed the trial. During the nitrite phase, there was no significant difference in mean peak oxygen consumption as compared with the placebo phase (13.5 vs 13.7 mL/kg/min; difference, -0.20 [95% CI, -0.56 to 0.16]; P =.27). There were no significant between-treatment phase differences in daily activity levels (5497 vs 5503 accelerometry units; difference, -15 [95% CI, -264 to 234]; P =.91), Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (62.6 vs 61.9; difference, 1.1 [95% CI, -1.4 to 3.5]; P =.39), functional class (2.5 vs 2.5; difference, 0.1 [95% CI, -0.1 to 0.2]; P =.43), echocardiographic E/e′ ratio (16.4 vs 16.6; difference, 0.1 [95% CI, -1.2 to 1.3]; P =.93), or N-terminal fragment of the prohormone brain natriuretic peptide levels (520 vs 533 pg/mL; difference, 11 [95% CI, -53 to 75]; P =.74). Worsening heart failure occurred in 3 participants (2.9%) during the nitrite phase and 8 (7.6%) during the placebo phase. Conclusions and Relevance: Among patients with HFpEF, administration of inhaled inorganic nitrite for 4 weeks, compared with placebo, did not result in significant improvement in exercise capacity. Trial Registration: ClinicalTrials.gov Identifier: NCT02742129.