Adenosin to Rapidly Reverse Left Ventricle Impairment in Takotsubo Syndrome (TITAN)
Primary Purpose
Takotsubo Cardiomyopathy, Takotsubo Syndrome
Status
Terminated
Phase
Phase 2
Locations
Italy
Study Type
Interventional
Intervention
Adenosine
Saline solution
Sponsored by
About this trial
This is an interventional treatment trial for Takotsubo Cardiomyopathy
Eligibility Criteria
Inclusion Criteria:
- 18 years old
- Evidence of typical anatomical pattern to the left ventriculography (total akinesia of the mid-apical segments with hypercontractility basal segments) associated with the presence of criteria for the diagnosis of Takotsubo syndrome (Table 1)
- signing of informed consent
Exclusion Criteria:
- allergy to adenosine
- known and documented diagnosis of asthma
- pre-existing ischemic heart disease
- presence of arrhythmic complication (AV block grade II type 2 and third degree)
Sites / Locations
- University Hospital of Ferrara
Arms of the Study
Arm 1
Arm 2
Arm Type
Experimental
Placebo Comparator
Arm Label
Adenosine
Saline solution
Arm Description
Patients in this arm will receive systemic infusion of adenosine at 140μg/kg/min for 3 minutes plus standard therapy according to current guidelines
Patients in this arm will receive systemic infusion of saline solution at 140μg/kg/min for 3 minutes plus standard therapy according to current guidelines
Outcomes
Primary Outcome Measures
left ventricle ejection fraction (%)
an indipendent corelab will review all images from 48-hour ecocardiography to establish LVEF value (%)
Secondary Outcome Measures
left ventricle ejection fraction (%)
an indipendent corelab will review all images from 24-hour ecocardiography to establish LVEF value (%)
left ventricle ejection fraction (%)
an indipendent corelab will review all images from 1-month ecocardiography to establish LVEF value (%)
wall motion score index
an indipendent corelab will review all images from 24-hour ecocardiography to calculate WMSI value (number)
wall motion score index
an indipendent corelab will review all images from 48-hour ecocardiography to calculate WMSI value (number)
wall motion score index
an indipendent corelab will review all images from 1-month ecocardiography to calculate WMSI value (number)
acute heart failure
it is defined as dyspnea + crackles on auscultation + signs on X-ray of chest congestion
intravenous diuretics
it is defined as the total count of mg of furosemide
emergency room admission
Access to the emergency room for dyspnea/heart failure
major adverse events
cumulative incidence of all-cause death and hospital admission for cardiovascular causes
hypokinetic arrhythmias
cumulative occurrence of hypokinetic arrhythmias (asystole, atrio-venticular block) in the course of administration of adenosine as shown by electrocardiogram recording
arterial hypotension
persistent hypotension (arterial blood pressure <90 mmHg) during administration of adenosine as shown by invasive blood pressure recording
side effects
Persistent symptoms (nausea, dyspnea, hot flush, etc.) that require premature discontinuation of the administration of adenosine
Full Information
NCT ID
NCT02867878
First Posted
August 10, 2016
Last Updated
October 19, 2018
Sponsor
University Hospital of Ferrara
1. Study Identification
Unique Protocol Identification Number
NCT02867878
Brief Title
Adenosin to Rapidly Reverse Left Ventricle Impairment in Takotsubo Syndrome
Acronym
TITAN
Official Title
Rapid Recovery of Left Ventricular Function in Patients With Takotsubo Syndrome Undergoing Systemic Infusion of Adenosine: a Randomized Controlled Trial (TITAN Study)
Study Type
Interventional
2. Study Status
Record Verification Date
October 2018
Overall Recruitment Status
Terminated
Why Stopped
inability to recruiti a sufficient number of patients
Study Start Date
August 2016 (Actual)
Primary Completion Date
October 2018 (Actual)
Study Completion Date
October 2018 (Actual)
3. Sponsor/Collaborators
Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
University Hospital of Ferrara
4. Oversight
Data Monitoring Committee
Yes
5. Study Description
Brief Summary
The investigators will randomize patients admitted to hospital with Takotsubo diagnosis to systematic high-dose adenosine infusion for 3 minutes (in addition to standard of care) vs. standard of care. The primary aim of the study is to demonstrate that adenosine infusion is associated with a larger and more rapid recovery of left ventricle function.
Detailed Description
Takotsubo syndrome is a heart condition that is characterized by the rapid onset of left ventricular dysfunction, usually reversible, and meeting the following diagnostic criteria:
Transient alterations of regional contractility of the myocardial wall of the right or left ventricle, which are frequently, but not always, preceded by a stressful event (emotional or physical).
The regional changes in contractility of the myocardial wall, often extend beyond the distribution of a single coronary vessel, and often result in a circumferential ventricular dysfunction of the involved segments.
Absence of a culprit coronary lesion (eg. Of atherosclerotic plaque rupture, thrombus formation, coronary dissection) or other pathological conditions that may explain the regional changes in contractility of the myocardial wall (eg. Hypertrophic cardiomyopathy, viral myocarditis)
Reversible electrocardiographic abnormalities of the EKG (ST-T segment elevation or depression, new onset of left bundle branch block, inversion of t wave and / or QTc elongation) during the acute phase (3 months).
Significant increase in serum natriuretic peptide (BNP or NT-proBNP) during the acute phase
Troponin significant increase, but relatively small, (disparity between the degree of left ventricular dysfunction and the value of troponin).
The recovery of left ventricular function during follow-up (3-6 months).
Epidemiology Since the Takotsubo syndrome has been described for the first time in 1991, its incidence, with the passing of years has been increasing, thanks to the possibility with networks for the treatment of acute myocardial infarction, to have a early access to coronary angiography study. Currently this syndrome accounts for 2% of all acute coronary syndromes who are undergoing coronary angiography.
Pathophysiology The pathophysiology of Takotsubo syndrome is complex, and not fully clarified. There are several causes have been suggested over the years to explain the occurrence of this syndrome (vascular and / or myocardial). One of the mechanisms suggested is that there is a systemic response, by the body, to a severe stress which causes a sudden increase of catecholamines endogenous and exogenous; this increase has an effect on the cardiovascular system leading to acute heart failure.
Stress is one of the most common causes behind the onset of this syndrome, and emotional stress (eg. Mourning,quarrel, etc.) and physical (eg. Surgical emergencies, obstetric or psychiatric), but it is not always a present condition.
Recent case reports and clinical studies have shown that patients with this syndrome may experience a reversible damage of the coronary microcirculation, which could be the basis of the important ventricular dysfunction that is observed in these patients. This characteristic may play a significant role in the management of these patients. In fact any targeted therapies to the rapid recovery of the coronary microcirculation function with subsequent improvement in left ventricular function could reduce or prevent the complications related to this case.
Complications During the acute phase of Takotsubo Syndrome the incidence of complications is frequent (18-34% involvement of the right ventricle; obstruction of left ventricular outflow 12-54%; mitral regurgitation 14-25%, 9-20% cardiogenic shock, ventricular thrombus 2-8%, 5-15% atrial fibrillation, ventricular arrhythmias 4-9%, 2-5% bradycardia-asystole) and these complications are often the consequence of left ventricular dysfunction. In fact, the presence of major depression of the ejection fraction (EF) is the main cause of complications in patients with Takotsubo and that the slow pace of recovery of normal EF is closely connected to this risk of complications.
Diagnosis Takotsubo syndrome diagnosis requires, as basic examinations, coronary angiography (allows us to exclude the coronary artery diseases and to highlight the presence of the typical pattern "apical balloon" to the ventriculography) and the echocardiogram ( allow us to highlight the regional alterations of left ventricular kinetics).
Risk Stratification Patients in whom the diagnosis of Takotsubo syndrome is made, they have to be stratified according to their risk profile in patients at high and low risk
Therapy Recently the European Society of Cardiology has prepared a document in which it is suggested therapy to be performed in patients with Takotsubo syndrome according to risk stratification and clinical and echocardiographic data, based on a consensus among the authors in the absence of current randomized clinical studies in support of this strategy.
Mortality The data available report an in-hospital (1-4.5%) and 5 years (3-17%) mortality non-negligible.
Follow-up A recovery of ventricular function is shown at 3-6 months from acute event
Rationale of the study In patients with symptomatic Takotsubo, therapeutic strategies currently used are designed to address, not the pathophysiological mechanism underlying this event, but the complications faced by patients (ie acute heart failure, arrhythmias and hyperkinetic left ventricular thrombosis). No data are currently available about targeted therapies to the treatment of Takotsubo syndrome.
Adenosine is an extracellular signaling molecule that plays a fundamental role in human physiology. Its main effects are: vascular vasodilation, regulation of the activity of the sympathetic nervous system, antithrombotic and regulating blood pressure and heart rate. One of the main uses of adenosine in the cardiovascular field is the production of vasodilation of the coronary microcirculation to produce hyperemia, as for example in the assessment of intermediate coronary stenoses using fractional flow reserve (FFR). It also finds use even in the course of acute myocardial infarction in reducing the phenomenon of slow-flow in the course of primary angioplasty, even if the results of the studies currently available are not unambiguous interpretation.
Galiuto et al. have demonstrated that, regardless of the underlying etiology, in patients with Takotsubo syndrome, it shows the presence of an acute and reversible vasoconstriction of the coronary microcirculation, which may represent a common pathophysiologic mechanism in these patients. In the study the investigators underline also as the use of a systemic infusion of adenosine at a dose of 140 micrograms / kg / min for 90 seconds determines an initial improvement, statistically significant, of the left ventricular function in these patients. The study was observational, and have not been taken into consideration clinical outcomes.
Numerous studies performed in patients with STEMI (ST-segment elevation myocardial infarction) have shown that the adenosine infusion systems, although at high doses, causes only mild adverse effects (es. dyspnea, chest pain, transient ventricular atrium block, hypotension ) and all quick resolution with the suspension of the infusion.
Objective of the study The objective of this study is to demonstrate that in patients with Takotsubo syndrome diagnosis, the use of adenosine infusion at high doses, immediately after the diagnosis of disease, and the absence of documentation of coronary artery disease, it is able to enhance the EF of these patients to 48 hours after diagnosis, compared with standard therapy.
Study Design It is an multicenter, randomized, single-blind study, phase IIa.
Once coronary angiography demonstrated the absence of coronary artery disease and confirmed the diagnosis of Takotsubo syndrome patients will undergo a baseline echocardiography and then randomized, using a randomization system electronic, 1: 1 to receive:
Systemic infusion of adenosine to 140μg / kg / min for 3 minutes + standard therapy
Placebo (saline to 3 minutes) + standard therapy
Randomization will be stratified by the following variables:
gender (male vs. female)
age (<65 years vs. ≥65 years) The standard therapy, will be allocated based on the risk stratification of patients enrolled. Patients will then be assessed by echocardiography at 24 hours, 48 hours and 1 month according to the parameters given in the echocardiographic analysis section.
All patients will be followed up with clinical follow-up up to one year.
PRESPECIFIED SUBSTUDY As has been shown in previous studies, patients with Takotsubo syndrome have reversible coronary microvascular damage.
The purpose of our study is to assess whether the infusion of high-dose adenosine e.v favors the improvement of left ventricular ejection function quickly.
With this sub-study we want to evaluate, also, if there is also in our series a damage of the coronary microcirculation.
Patients participating in the sub-study, randomized in the Adenosine arm, the evaluation of coronary microcirculation will be performed by calculating the IMR (microcirculatory resistance index) during the infusion of adenosine required by randomization.
The IMR is a validated method for measuring the function of the coronary microcirculation. By using a previously positioned guide pressure on the left anterior descendent (LAD) coronary artery, IMR is evaluated by the thermodilution technique analyzing the transit time of a predetermined quantity (3 ml) of saline at room temperature injected into the coronary artery.
3 consecutive injection of 3 mL of saline solution are performed at baseline, and evaluated the average transit time for resting (Tmn). Later, during maximal hyperemia induced by systemic infusion of Adenosine a140μg / kg / min, 3 new injections of saline at room temperature are performed, and the mean transit temple during hyperemia (Tmnhyp) is measured. Tmnhyp multiplying by the average value of distal coronary pressure (Pd) registered during maximal hyperemia, get the IMR value (IMR: Tmnhyp x Pd) which is considered in the normal range if less than 25. A value above 25 indicates the presence of a damage of the coronary microcirculation.
6. Conditions and Keywords
Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Takotsubo Cardiomyopathy, Takotsubo Syndrome
7. Study Design
Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Parallel Assignment
Masking
Participant
Allocation
Randomized
Enrollment
5 (Actual)
8. Arms, Groups, and Interventions
Arm Title
Adenosine
Arm Type
Experimental
Arm Description
Patients in this arm will receive systemic infusion of adenosine at 140μg/kg/min for 3 minutes plus standard therapy according to current guidelines
Arm Title
Saline solution
Arm Type
Placebo Comparator
Arm Description
Patients in this arm will receive systemic infusion of saline solution at 140μg/kg/min for 3 minutes plus standard therapy according to current guidelines
Intervention Type
Drug
Intervention Name(s)
Adenosine
Intervention Type
Drug
Intervention Name(s)
Saline solution
Primary Outcome Measure Information:
Title
left ventricle ejection fraction (%)
Description
an indipendent corelab will review all images from 48-hour ecocardiography to establish LVEF value (%)
Time Frame
48 hours
Secondary Outcome Measure Information:
Title
left ventricle ejection fraction (%)
Description
an indipendent corelab will review all images from 24-hour ecocardiography to establish LVEF value (%)
Time Frame
24 hours
Title
left ventricle ejection fraction (%)
Description
an indipendent corelab will review all images from 1-month ecocardiography to establish LVEF value (%)
Time Frame
1 month
Title
wall motion score index
Description
an indipendent corelab will review all images from 24-hour ecocardiography to calculate WMSI value (number)
Time Frame
24 hours
Title
wall motion score index
Description
an indipendent corelab will review all images from 48-hour ecocardiography to calculate WMSI value (number)
Time Frame
48 hours
Title
wall motion score index
Description
an indipendent corelab will review all images from 1-month ecocardiography to calculate WMSI value (number)
Time Frame
1 month
Title
acute heart failure
Description
it is defined as dyspnea + crackles on auscultation + signs on X-ray of chest congestion
Time Frame
1 month
Title
intravenous diuretics
Description
it is defined as the total count of mg of furosemide
Time Frame
1 month
Title
emergency room admission
Description
Access to the emergency room for dyspnea/heart failure
Time Frame
1 month
Title
major adverse events
Description
cumulative incidence of all-cause death and hospital admission for cardiovascular causes
Time Frame
1 year
Title
hypokinetic arrhythmias
Description
cumulative occurrence of hypokinetic arrhythmias (asystole, atrio-venticular block) in the course of administration of adenosine as shown by electrocardiogram recording
Time Frame
1 hour
Title
arterial hypotension
Description
persistent hypotension (arterial blood pressure <90 mmHg) during administration of adenosine as shown by invasive blood pressure recording
Time Frame
1 hour
Title
side effects
Description
Persistent symptoms (nausea, dyspnea, hot flush, etc.) that require premature discontinuation of the administration of adenosine
Time Frame
1 hour
10. Eligibility
Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria:
18 years old
Evidence of typical anatomical pattern to the left ventriculography (total akinesia of the mid-apical segments with hypercontractility basal segments) associated with the presence of criteria for the diagnosis of Takotsubo syndrome (Table 1)
signing of informed consent
Exclusion Criteria:
allergy to adenosine
known and documented diagnosis of asthma
pre-existing ischemic heart disease
presence of arrhythmic complication (AV block grade II type 2 and third degree)
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Matteo Tebaldi, MD
Organizational Affiliation
Azienda Ospedaliera Universitria di Ferrara
Official's Role
Principal Investigator
Facility Information:
Facility Name
University Hospital of Ferrara
City
Cona
State/Province
Ferrara
ZIP/Postal Code
44124
Country
Italy
12. IPD Sharing Statement
Plan to Share IPD
Undecided
Learn more about this trial
Adenosin to Rapidly Reverse Left Ventricle Impairment in Takotsubo Syndrome
We'll reach out to this number within 24 hrs