A Phase II Randomized, Placebo-Controlled, Double-Blinded Study Evaluating the Effects of Ataciguat (HMR1766) on Aortic Valve Calcification in Patients With Moderate Calcific Aortic Valve Stenosis
Phase: PHASE2
Conditions: Aortic Valve Stenosis
Sponsor: Mayo Clinic

 
 
A PHASE II RANDOMIZED, PLACEBO-
CONTROLLED, DOUBLE-BLINDED STUDY 
EVALUATING THE EFFECTS OF ATACIGUAT 
(HMR1766) ON AORTIC VALVE CALCIFICATION 
IN PATIENTS WITH MODERATE CALCIFIC 
AORTIC VALVE STENOSIS 
 
NCT02481258 
 
1/8/2014 

Long-term efficacy of Ataciguat in Patients with Moderate CAVS 
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A PHASE II RANDOMIZED, PLACEBO-CONTROLLED, 
DOUBLE-BLINDED STUDY EVALUATING THE EFFECTS OF 
ATACIGUAT (HMR1766) ON AORTIC VALVE CALCIFICATION 
IN PATIENTS WITH MODERATE CALCIFIC AORTIC VALVE 
STENOSIS 
 
 
 
Regulatory Sponsor: 
Jordan D. Miller, PhD 
Department of Surgery 
Mayo Clinic 
Rochester, Minnesota 
 
Funding Sponsor: 
(Optional) 
National Center for Accelerating Translational Sciences 
National Institutes of Health 
301-435-0824 (Dr. Christine Colvis, Program Officer) 
 
Study Product: 
Ataciguat 
Protocol Number: (IRBe) 
 
IRBe # 14-006469 
 
IND Number: 
119,829 
 
 
 
 
 
Initial version:1/8/2014 Version 5 
 
 
 
 

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Table of Contents 
 
STUDY SUMMARY ...................................................................................................................................... 5 
1 
INTRODUCTION ................................................................................................................................. 6 
1.1 
BACKGROUND ............................................................................................................................................. 6 
1.2 
INVESTIGATIONAL AGENT .......................................................................................................................... 7 
1.3 
PRE-CLINICAL DATA................................................................................................................................... 8 
1.4 
CLINICAL DATA TO DATE ......................................................................................................................... 10 
1.5 
DOSE RATIONALE AND RISK/BENEFITS ..................................................................................................... 12 
2 
STUDY OBJECTIVES ........................................................................................................................ 13 
3 
STUDY DESIGN ................................................................................................................................. 17 
3.1 
GENERAL DESIGN ..................................................................................................................................... 17 
3.2 
PRIMARY STUDY ENDPOINTS .................................................................................................................... 18 
3.3 
PRIMARY SAFETY ENDPOINTS ................................................................................................................... 18 
4 
SUBJECT SELECTION ENROLLMENT AND WITHDRAWAL ...................................................... 20 
4.1 
INCLUSION CRITERIA ................................................................................................................................ 20 
4.2 
EXCLUSION CRITERIA ............................................................................................................................... 20 
4.3 
SUBJECT RECRUITMENT, ENROLLMENT AND SCREENING ......................................................................... 20 
4.4 
EARLY WITHDRAWAL OF SUBJECTS.......................................................................................................... 21 
4.4.1 
Data Collection and Follow-up for Withdrawn Subjects .............................................................. 21 
5 
STUDY DRUG .................................................................................................................................... 23 
5.1 
DESCRIPTION ............................................................................................................................................ 23 
5.2 
TREATMENT REGIMEN .............................................................................................................................. 23 
5.3 
METHOD FOR ASSIGNING SUBJECTS TO TREATMENT GROUPS .................................................................. 23 
5.4 
PREPARATION AND ADMINISTRATION OF STUDY DRUG ............................................................................ 24 
5.5 
SUBJECT COMPLIANCE MONITORING ........................................................................................................ 24 
5.6 
PACKAGING .............................................................................................................................................. 24 
5.7 
MASKING/BLINDING OF STUDY ................................................................................................................ 24 
5.8 
RECEIVING, STORAGE, DISPENSING AND RETURN OF STUDY DRUG .......................................................... 25 
5.8.1 
Return or Destruction of Study Drug ......................................................................................... 25 
6 
METHODS ......................................................................................................................................... 28 
6.1 
SCREENING AND SELECTION OF PATIENTS ................................................................................................. 28 
6.2 
OVERVIEW OF VISIT 2 ............................................................................................................................... 30 
6.3 
OVERVIEW OF VISIT 3 ......................................................................... ERROR! BOOKMARK NOT DEFINED. 
7 
STATISTICAL PLAN ......................................................................................................................... 33 
7.1 
PRIMARY HYPOTHESIS .............................................................................................................................. 33 
7.2 
SUBJECT POPULATION FOR ANALYSIS ....................................................................................................... 33 
7.3 
DOSE (DE)-ESCALATION DECISION ...................................................... ERROR! BOOKMARK NOT DEFINED. 
7.4 
SAMPLE SIZE ............................................................................................................................................. 33 
7.5 
ADDITIONAL ANALYSES ........................................................................................................................... 34 
7.6 
SELECTION OF DOSE TO CARRY-FORWARD INTO NEXT TRIAL .............. ERROR! BOOKMARK NOT DEFINED. 
8 
SAFETY AND ADVERSE EVENTS ................................................................................................... 34 
8.1 
DEFINITIONS ............................................................................................................................................. 34 
8.2 
RECORDING OF ADVERSE EVENTS ............................................................................................................ 36 
8.3 
REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS .......................................... 36 
8.3.1 
Sponsor-Investigator reporting: notifying the Mayo IRB ............................................................. 36 

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8.3.2 
Sponsor-Investigator reporting: Notifying the FDA ..................................................................... 36 
8.4 
UNBLINDING PROCEDURES ....................................................................................................................... 37 
8.5 
STOPPING RULES ....................................................................................................................................... 37 
8.6 
MEDICAL MONITORING ............................................................................................................................ 37 
8.6.1 
Internal Data and Safety Monitoring Board ............................................................................... 37 
9 
DATA HANDLING AND RECORD KEEPING .................................................................................. 38 
9.1 
CONFIDENTIALITY..................................................................................................................................... 38 
9.2 
SOURCE DOCUMENTS................................................................................................................................ 39 
9.3 
CASE REPORT FORMS ............................................................................................................................... 39 
9.4 
RECORDS RETENTION ............................................................................................................................... 40 
10 
STUDY MONITORING, AUDITING, AND INSPECTING ................................................................ 41 
10.1 
STUDY MONITORING PLAN ....................................................................................................................... 41 
10.2 
AUDITING AND INSPECTING ...................................................................................................................... 41 
11 
ETHICAL CONSIDERATIONS ......................................................................................................... 41 
12 
STUDY FINANCES ............................................................................................................................ 41 
12.1 
FUNDING SOURCE ..................................................................................................................................... 41 
12.2 
CONFLICT OF INTEREST ............................................................................................................................. 42 
12.3 
SUBJECT STIPENDS OR PAYMENTS ............................................................................................................ 42 
13 
PUBLICATION PLAN ....................................................................................................................... 42 
14 
REFERENCES ................................................................................................................................... 43 
 
 
 
 
 
 
 
 

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List of Abbreviations 
 
 
LIST OF ABBREVIATIONS 
AE 
Adverse Event/Adverse Experience 
CAVS 
Calcific Aortic Valve Stenosis 
CFR 
Code of Federal Regulations 
CRF 
Case Report Form 
DSMB 
Data and Safety Monitoring Board 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s Brochure 
 
 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
PHI 
Protected Health Information 
PI 
Principal Investigator 
SAE 
Serious Adverse Event/Serious Adverse Experience 
SOP 
Standard Operating Procedure 
 
 
 
 
 
 

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Study Summary 
Title 
A Phase II randomized, placebo-controlled, double-blinded study 
evaluating the safety and efficacy of ataciguat (HMR1766) in patients 
with moderate calcific aortic valve stenosis 
Running Title 
Long term efficacy of Ataciguat in patients with moderate CAVS 
Protocol Number 
14-006469 
Phase 
Phase II 
Methodology 
Double Blinded, randomized, placebo-controlled study 
Overall Study 
Duration 
12 months  
Subject 
Participation 
Duration 
12 months (Screen Visit + 2 Follow Up Visits)  
Single or Multi-Site  Single site 
Objectives 
The primary objective of the current study is to determine whether 
Ataciguat (HMR1766) slows progression of valve calcification in patients 
with moderate calcific aortic valve stenosis.  A secondary objective is to 
determine whether Ataciguat slows progression of left ventricular 
dysfunction in patients with moderate calcific aortic valve stenosis. 
Number of Subjects 
100 
Diagnosis and Main 
Inclusion Criteria 
Mild to moderate calcific aortic valve stenosis.  Aortic valve area 
greater than 1.0 cm2 but less than 2.0 cm2 by echocardiographic 
evaluation and valuvlar calcium levels >150 AU by chest CT scanning.   
Study Product, 
Dose, Route, 
Regimen 
• Ataciguat/HMR1766 and matching placebo 
• Oral administration of 200 mg gelatin capsules packaged in 
alu/alu blister packs 
• Dosing 
• Anticipated dose of 200 mg ataciguat or matching placebo (=  
4 capsules of 50 mg or matching placebo) given once daily in 
the morning, with food.  This dosing will be continued for the 
duration of the study period. 
• If the drug is not tolerated, the patient’s involvement in the 
study will be terminated (i.e., there is no de-escalation option) 
Duration of 
Administration 
12 months 
Reference therapy 
Placebo capsules will be provided as a reference.   
Statistical 
Methodology 
 A repeated measures ANOVA with Bonferonni-corrected T-tests will 
be used to detect the impact of Ataciguat/HMR1766 on aortic valve 
calcification (assessed using CT scanning), aortic valve function 
(assessed using echocardiography), or left ventricular function (using 
echocardiography).  

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1 Introduction 
This document is a protocol for a human research study. This study will be carried out in 
accordance with the applicable United States government regulations and Mayo Clinic 
research policies and procedures.  
1.1 
Background 
Hemodynamically significant calcific aortic valve stenosis (CAVS) affects 3% of the 
population over age 65, and patients with even moderate aortic valve stenosis (peak velocity 
of 3-4 m/sec) have a 5 year event-free survival of less than 40%. Presently, there are no 
effective treatments to slow progression of aortic valve calcification, and aortic valve 
replacement is the only available treatment for advanced CAVS. Thus, major aims of our 
research program include: 1) the use of integrative approaches to identify mechanisms 
contributing to initiation and progression of CAVS, and 2) the use of integrative approaches to 
identify therapeutic interventions that slow progression of CAVS without negatively 
impacting other organ systems/tissues in vivo (e.g., skeletal ossification). In the present 
UH2/UH3 application, we propose that activators of oxidized soluble guanylate cyclase (sGC) 
are a novel therapeutic intervention that can slow progression of CAVS. During the UH3 
phase of the grant, we aim to provide key proof-of-concept data that Ataciguat/HMR1766: 1) 
is well tolerated by patients with mild to moderate CAVS, 2) slows progression of CAVS in a 
robust mouse model of valvular calcification and stenosis, 3) reduces osteogenic signaling in 
human aortic valve interstitial cells in vitro, and 4) effectively activates oxidized sGC and 
attenuates osteogenic signaling in valves from patients with severe CAVS. Upon meeting 
appropriate milestones during the UH2 phase of the grant, we will rapidly move towards the 
UH3 phase of the grant, where we will examine the effects of chronic ataciguat treatment on 
accumulation of aortic valve calcium, progression of aortic valve and ventricular dysfunction, 
and inflammatory cytokine levels in patients with mild to moderate CAVS. Collectively, we 
believe the proposed studies have a high likelihood of not only providing new insight into 
fundamental mechanisms regulating gene expression in CAVS, but are also likely to identify 
Ataciguat as a novel therapeutic agent to slow progression of CAVS in humans.  
 
Hemodynamically significant aortic valve stenosis affects 3% of the population over age 65, 
and patients with even moderate aortic valve stenosis (peak velocity of 3-4 m/sec) have a 5 
year event-free survival of less than 40%. Presently, there are no effective treatments to slow 
progression of aortic valve calcification, and aortic valve replacement is the only available 
treatment for advanced aortic valve stenosis. This proposal tests the novel hypothesis that 
activation of oxidized soluble guanylate cyclase with Ataciguat/HMR1766 will slow 
progression of valve calcification and dysfunction. Our UH2/UH3 application is uniquely 
designed to not only demonstrate efficacy of treatment in humans, but also to lend key 
insights into the biological processes underlying changes in aortic valve function using robust 
animal models, in vitro cell assays, and in vivo measurements of sGC activation and 
suppression of osteogenic signaling in human valves. Collectively, we believe 
Ataciguat/HMR1766 provides an innovative therapeutic approach to reduce morbidity and 
mortality associated with aortic valve calcification in humans.   
 

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Brief overview and Clinical Importance: Hemodynamically significant aortic valve stenosis 
(CAVS) is a tremendously important clinical problem affecting ~3% of the population over 
age 659, and patients with even moderate aortic valve stenosis have a 5 year event-free 
survival of less than 40%10-13. More than 25% of patients over the age of 65 have aortic valve 
calcification and sclerosis, which substantially increases risk for adverse cardiovascular events 
and all-cause mortality7, 8. Presently, no medical treatments have been shown to slow 
progression of aortic valve calcification or progression of stenosis in humans. Recent studies 
in pre-clinical models of disease, however, suggest that increasing nitric oxide signaling may 
be a useful intervention to attenuate osteogenic signaling and slow progression of CAVS1, 2. 
While attractive, harnessing NO signaling in vivo has proven to be logistically difficult due to 
elevated levels of oxidative stress and the depletion of NO synthase cofactors in end-stage 
CAVS3, 4. Furthermore, reductions in antioxidant capacity in CAVS strongly favor oxidation 
of soluble guanylate cyclase, thus rendering it insensitive to NO5, 6. To circumvent these 
problems, we propose that Ataciguat (HMR1766) will slow progression of calcific aortic 
valve disease, through preferential activation of oxidized soluble guanylate cyclase (sGC) and 
subsequent conveying of protective effects associated with NO signaling. More specifically, 
we propose that activation of oxidized sGC in CAVS will attenuate pro-osteogenic signaling, 
reduce pro-fibrotic signaling, and ultimately slow progression of aortic valve dysfunction in 
pre-clinical animal models of mild to moderate valve calcification, and ultimately, in humans 
with mild to moderate valve calcification and stenosis. 
 
 
1.2 
Investigational Agent 
 
The investigational agent for this study is  HMR1766 (ataciguat sodium) manufactured and 
supplied by Sanofi-Aventis Research and Development. 
 
 
Drug Substance: Ataciguat 
Drug substance used: 
 
Ataciguat sodium 
Chemical name according 
to IUPAC: 
 
 
5-Chloro-2-(5-chloro-thiophene-2-sulfonylamino)-N-[4-
(morpholine-4-sulfonyl)-phenyl]-benzamide, sodium salt 
Laboratory code number: 
 
HMR1766 
S982766 
Sodium salt of HMR1514 
CAS registry number: 
 
254976-06-2 

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Structural formula: 
 
 
 
Relative molecular mass: 
 
576.50 (active moiety), 598.49 (sodium salt) 
Structural similarities to 
other known compounds: 
 
 
HMR1766 (ataciguat sodium) shows no structural similarities to 
other compounds approved as active pharmaceutical ingredient 
Appearance: 
 
White to pastel yellow powder 
Solubility at 37°C: 
 
Water (resulting pH: 11.1):Very slightly soluble 
 
 
 
 
 
HMR1766 is a novel, nitric oxide (NO) independent activator of soluble guanylate cyclase 
(sGC) that preferentially activates the oxidized form of sGC, which is insensitive to NO. The 
clinical development of HMR1766 was initially proposed for the symptomatic treatment of 
peripheral arterial disease (PAD), Fontaine stage II (intermittent claudication). Currently, 
HMR1766 is being tested in the indication of neuropathic pain. 
 
1.3 
Pre-Clinical Data 
 
Non-clinical pharmacology: Neuropathic pain is caused by tissue damage, especially direct 
injury of the nervous system and neuronal inflammation. It is characterized by increased 
sensitivity to painful stimuli (hyperalgesia), perception of innocuous stimuli as painful 
(allodynia) and spontaneous pain. Inflammatory as well as immune mechanisms play an 
important role. Schwann cells, satellite cells in the dorsal root ganglia, components of the 
peripheral immune system, spinal microglia and astrocytes are involved. HMR1766 – through 
activation of sGC and, consequently, elevation of cGMP levels – is expected to be effective in 
the treatment of neuropathic pain through blockade of glial cell activation and an increase of 
the nociceptive threshold through opening of K+-ATP channels. 
 
HMR1766 significantly and dose-dependently reduced tactile and cold allodynia in the spared 
nerve injury (SNI) induced mouse model of neuropathic pain. Furthermore HMR1766 
significantly and dose-dependently reduced thermal hyperalgesia in the Carrageenan-induced 
mouse model of inflammatory triggered pain. 
 

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Effects on vasodilatation and endothelial function have been investigated in cardiovascular 
animal models. In a unilateral hind limb ischemia model in diabetic rats, ataciguat reduced 
muscle fatigue and increased perfusion pressure in the ischemic leg. In ApoE knockout mice 
on a high fat diet, HMR1766 inhibited the development of endothelial dysfunction and 
markedly reduced the development of atherosclerotic plaques. It induced concentration-
dependent vasorelaxation in preconstricted aortic rings without tolerance development or 
induction of cross-tolerance to nitrates. In various animal models, HMR1766 positively 
effected on markers of coronary function, coronary thrombosis, and myocardial function 
without alteration of hemodynamic parameters. 
 
HMR1766 blocked human ether-à-go-go related gene (hERG) currents at a concentration 
inhibiting 50% of an assay response (IC50) of 37 μM, which is ~100-fold higher than the 
concentration giving 50% of the maximum effect (EC50) for the activation of sGC. In 
Purkinje fibers, HMR1766 induced a concentration-dependent decrease of action potential 
duration at 3 and 10 μM, slightly decreased action potential amplitude and maximum rate of 
rise of the action potential (Vmax) at 10 μM, and caused pronounced modifications of all 
parameters associated with depolarization of the cellular membrane at 30 μM. Decreased 
blood pressure (BP), tachycardia with related electrocardiographic (ECG) changes (decreased 
PR-, PQ-, and QT-intervals), but no effects on QTc were observed after oral administration of 
single doses up to 400 mg/kg in dogs. Likewise, intravenous (IV) doses up to 30 mg/kg 
decreased BP and increased heart rate (HR), but  had no significant effect on QTc in dogs. 
HMR1766 had no effect on general behavior, body temperature or locomotor behavior, 
respiratory parameters, blood glucose levels, and salidiuresis in rats.  
 
Long-term treatment of low density lipoprotein receptor-deficient, apolipoprotein B100-only 
mice with HMR1766 significantly slowed progression of aortic valve dysfunction in  female 
mice fed a Western diet for 9 months. Long-term treatment of male mice of the same strain 
(low density lipoprotein receptor-deficient, apolipoprotein B100-only) with HMR1766 did not 
slow progression of aortic valve dysfunction.  Long-term treatment with HMR1766 did not 
significantly alter blood pressure in low density lipoprotein receptor-deficient, apolipoprotein 
B100-only mice of either sex, and did not significantly alter endothelium-dependent or 
endothelium-independent relaxation of conduit vessels in low density lipoprotein receptor-
deficient, apolipoprotein B100-only mice of either sex.       
 
Pharmacokinetics and product metabolism in animals: HMR1766 was rapidly absorbed 
following oral administration, with time to maximum concentration (tmax) at ~0.5 hour in rats 
and ~2.7 hours in dogs. Oral bioavailability was almost complete in both species. Following 
IV administration, HMR1766 was rapidly eliminated with a half-life of <0.5 hour in rat and 
~2 hours in dog. After oral administration of [14C] HMR1766, the compound and/or its 
metabolites showed a high plasma protein binding, were ubiquitously distributed, had a low 
central nervous system penetration, showed no significant retention in any tissues, and did not 
bind to formed blood elements. After oral administration to female rats or rabbits (dams), very 
low radioactivity levels were measurable in the fetuses. In a rat study, 74% of the plasma total 
radioactivity at tmax was accounted for by parent compound. Independent of the route of 
administration, HMR1766 was excreted almost completely via the feces in rats and dogs. 

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When administered orally, radiolabeled HMR1766 was primarily excreted as parent 
compound in rats, and primarily as metabolites in dogs. 
 
Toxicology: Acute toxicity with HMR1766 revealed median lethal dose (LD50) values of ~100 
to 200 mg/kg after IV administration (rats and mice), ~250 (rats) and ~500 (mice) mg/kg after 
subcutaneous (SC) administration, and >5000 mg/kg body weight (rats and mice) after oral 
administration. In the 6-month oral toxicity study in rats, slight signs of anemia and slightly 
increased liver weights were observed at 500 mg/kg/day. In the 6 month oral toxicity study in 
dogs, increased bilirubin, alkaline phosphatase values, and myocardial steatosis were 
observed. The peripheral muscles also showed markedly increased lipid storage at 530 
mg/kg/day. The no observed adverse effect level (NOAEL) was 100 mg/kg in 6-month studies 
with rats and dogs. No compound-related effects were observed in dogs after oral 
administration up to 200 mg/kg/day over a period of 12 months. Developmental toxicity was 
observed in rats at a very high dose, at which distinct maternal toxicity occurred (1500 
mg/kg/day). In rabbits, an increased incidence of variations, which are known to occur 
spontaneously, was seen at the highest dose evaluated (1000 mg/kg/day), a dose which was 
maternally toxic. HMR1766 did not affect mating behavior and fertility or early embryonic 
development in rats. HMR1766 was not mutagenic in the Ames test or the unscheduled DNA 
synthesis (UDS) test ex vivo. Although HMR1766 was positive in a mammalian chromosome 
aberration test in vitro and in human lymphocytes in vitro at highly cytotoxic concentrations, 
it was negative in vivo in the micronucleus test in mouse bone marrow, the chromosome 
aberration test in rat bone marrow and the comet assay in rat livers.   
 
Human exposure under steady state conditions in repeated administration of 200 mg/day 
reaches values that are still below those at the NOAEL in the 12-month dog study and at a 
dose level in the 6-month rat study, at which only minimal effects were observed. 
 
 
1.4 
Clinical Data to Date 
Ataciguat is being developed as a novel, NO-independent activator of sGC that preferentially 
activates the oxidized form of sGC, which is insensitive to NO. Currently, ataciguat is being 
tested in the indication of neuropathic pain. 
 
Sixteen clinical studies in healthy subjects have been clinically completed and 298 healthy 
subjects (245 men, 53 women) have been dosed with ataciguat. Four clinical studies in 
patients have been completed: a study in 23 patients with CAD, a study in 343 patients with 
stable angina, a study in 553 patients with PAD, and a study with 14 patients with mild-to-
moderate calcific aortic valve stenosis. To date, oral dosages of 25 mg to 200 mg ataciguat 
have been given as single doses and oral dosages of 5 mg to 200 mg as repeated doses, the 
highest dosage regimen being 200 mg once daily for 26 weeks.   
 
Ataciguat is to be administrated orally, once per day, with breakfast. (Under fasting 
conditions, the absorption was quicker [shorter tmax] and the exposure was greater [larger 
AUC]. The elimination half-life [t½,z], however, was unchanged [~22 hours].)   
 

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Effects in humans 
Clinical studies conducted in healthy subjects and patients with acute or chronic CAD or 
mild-to-moderate calcific aortic valve stenosis have not identified any safety findings of 
clinical relevance for the ongoing clinical development program. 
 
In addition, a good safety profile, comparable with placebo was found for all ataciguat dose 
groups (daily dose 25 mg, 100 mg, and 200 mg per day) in the 6-month, double-blind, placebo 
controlled Study DFI6174 (ACCELA) in patients with PAD (Fontaine II). 
 
In study DFI10569 (SERENEATI) in patients with neuropathic pain, overall, ataciguat 200 
mg was well tolerated.  Study treatment was permanently discontinued due to a TEAE in one 
ataciguat patient only (transient hyperbilirubinemia likely related to Gilbert's syndrome).  
There were no SAEs or deaths reported in this study. 
Possible risks: Ataciguat must not be given to pregnant and breast-feeding women, because no 
data are available in these subjects. Developmental toxicity was observed in rats at a very high 
dose, at which distinct maternal toxicity occurred. In rabbits, an increased incidence of 
variations, which are known to occur spontaneously, was seen at a high dose.  A double-
barrier method of contraception is required if ataciguat is administered to women of a child-
bearing potential. It is not known whether ataciguat is excreted in human milk. 
 
Drug interactions: 
Based on current knowledge of the mechanism of action, ataciguat might potentiate the effect 
of vasodilators on BP. 
 
Ataciguat is a moderate CYP2C9 inhibitor and might potentiate the effect of substrates of this 
isoenzyme, as confirmed  in studies with tolbutamide and warfarin. The increase in 
concentration should be considered when administering ataciguat with drugs that have narrow 
therapeutic indices and which are metabolized by this pathway. 
 
Ataciguat is a weak CYP3A inhibitor. The inhibitory potential  was confirmed in a clinical 
study by a slightly increased exposure to midazolam given as a comedication. Levonorgestrel 
and ethinylestradiol exposures were also increased when coadministered with ataciguat.  
These increased exposures should be considered when selecting doses of oral contraceptives.  
 
Clearance of ataciguat is mediated in part by CYP3A, but it is not a sensitive CYP3A 
substrate. Strong inhibitors of CYP3A4 may increase the plasma concentration of ataciguat, 
which was shown upon comedication with the inhibitor ketoconazole. However, exposure to 
ataciguat was increased by only 1.4-fold. 
 
In an ASA interaction study, platelet aggregation results were comparable between ataciguat + 
ASA and ASA alone. The findings of this study did not suggest that concomitant 
administration of ataciguat and ASA would pose a risk for the patient. 
 

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In the nitrate interaction study PDY6744, administration of ataciguat did not have any 
additional effect on hemodynamic responses to IV infusion of glyceroltrinitrate. 
  
1.5 
Dose Rationale and Risk/Benefits 
Following close examination of the Investigator Brochure and extensive discussions with our 
Industry partner (Sanofi), it is evident that short-term or long-term administration of Ataciguat 
has not elicited vasodilation/hypotension in normal subjects or in patients with cardiovascular 
disease.  This was confirmed by our initial safety study in patients with mild-to-moderate 
calcific aortic valve stenosis, in which treatment with HMR1766 (200 mg/day) for 14 
consecutive days did not elicit baseline hypotension or exacerbate hypotension induced by 
orthostatic stressors (e.g., transition from seated to standing).   
 
Ataciguat will be administered orally in the form of gelatin capsules containing 50 mg of 
drug.  The capsules will be individually packaged in aluminum blister packets, and subjects 
will be instructed to take four capsules (corresponding to their appropriate dose of 200 mg).  
As noted in section 1.2, pharmacokinetics and bioavailability data suggest excellent 
absorption and near complete bioavailability following oral ingestion of ataciguat.  
Circulating levels of ataciguat reach steady state following 14 days of treatment.  Thus, oral 
ingestion of the compound will be used for daily dosing with ataciguat to maintain steady 
state levels for the duration of the study.     
 
Risk/Benefit ratio:  The aim of this study is to determine whether Ataciguat effectively slows 
the progression of valve calcification and stenosis in patients with mild-to-moderate aortic 
valve stenosis.   This study is the second step in determining whether Ataciguat will be a 
useful treatment to slow progression of aortic valve stenosis in humans.  Participation in this 
study may directly benefit patients in the short term if they receive active compound and it is 
shown to protect against progression of aortic valve calcification and dysfunction.   
 
The risks associated with participation in this study are very low given our previous 
experiences with this drug in this patient population in our recent Phase I clinical trial.  
Furthermore, our combination of study design (e.g., rigorous screening and close monitoring), 
stringent eligibility criteria, and safety profile/historical safety record of this drug provided by 
Sanofi makes the risk associated with participation in these studies very low.   
 
Risk mitigation  
1) Our Clinical Research and Trials Unit (CRTU)is staffed by registered nurses who have 
extensive experience monitoring patients with a variety of medical conditions, including 
end-stage cancer and severe cardiovascular disease.  In order to mitigate risk associated 
with the current study, we plan to implement the following: 
a) Careful selection of patients by physicians who have extensive experience working 
with this patient population.  Dr. Sarano will screen and make final selection decisions 
on all patients with calcific aortic valve stenosis who will participate in these studies.  
Thus, by careful clinical evaluation, we will be able to identify patients who are 
hemodynamically stable and at exceedingly low risk for participation in this study. 

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b) Each patient will have a physical examination prior to admission to the CRTU (and 
subsequent testing/drug administration).  This will ensure that patients have not had 
significant alterations in their physiological/functional status since the time of their 
pre-surgical consultation. 
c) We will conduct frequent monitoring of blood pressure and EKG following drug 
administration.  A registered nurse will document blood pressures and 
electrocardiographic changes every 30 minutes for the first 2 hours following 
administration of the drug (while plasma concentrations are rapidly increasing).  In 
brief, each patient’s blood pressure will be measured using an automated arm cuff 
device (to detect sustained reductions in blood pressure) and beat-by-beat using a 
finger cuff device (to detect rapid reductions in pressure).  It is important to note that 
the frequency and intensity of monitoring in the CRTU would exceed that which a 
patient would typically receive if he/she was admitted to the hospital the night before 
surgery. 
d) We will ensure that a staff physician involved with this study is available for 
consultation for the full duration of each visit.  In the unlikely event of a severe 
adverse reaction to the drug, patients will be stabilized by the RMH Rapid Response 
Team (which, under Joint Commission guidelines, will respond within 2-4 minutes) 
and appropriately trained CRTU nursing staff, and transferred by the Gold Cross 
Ambulance to SMH for admission to the hospital through the Emergency Department, 
if necessary.   
e) As the drug used in the study has not undergone thorough testing for teratogenicity, all 
pre-menopausal women will need to complete point-of-care pregnancy testing prior to 
receiving the compound.   
 
2 Study Objectives 
 
Primary Objective:  To determine whether Ataciguat increases systemic sGC signaling, 
and halts accumulation of aortic valve calcium in patients with mild to moderate CAVS. 
 
Rationale: Progression of aortic valve calcification is the primary mechanism underlying 
progressive reductions in aortic valve area in aging humans.  Recent work from our group and 
others support a model in which valvular calcium may accumulate via osteogenic mechanisms 
similar to those observed in bone, suggesting that progression of valve disease may be a 
modifiable process.  Preliminary data for the UH2 phase of this application demonstrated that 
activation of soluble guanylate cyclase with HMR1766 abrogates BMP2-induced 
transcriptional responses, and that HMR1766 can slow accumulation of valvular calcium in an 
animal model of CAVS.  The effect of sGC activation in humans with moderate CAVS, 
however, remains unknown.   
 
Goal: Determine whether long-term treatment with HMR1766 will result in sustained 
increases in systemic sGC signaling and halt accumulation of aortic valve calcium in patients 
with mild to moderate CAVS. This will be done using computed tomography (CT) scanning 

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to evaluate aortic valve calcium levels, which is considered to be a “gold standard” for 
evaluating valvular calcium burden.    
Quantitative criteria for success: 
Key outcomes: 
1) Quantiative outcomes: 
a. Changes in aortic valve calcium levels measured by computed tomography 
scanning every 6 months of treatment during the trial (minimum of 12 
month treatment duration). 
i. Key comparision will be differences in the rate of change of 
calcium between patients receiving HMR1766 or placebo capsules 
 
 
 
 
Secondary Objective 1: To determine whether Ataciguat reduces levels of circulating 
inflammatory cytokines in patients with mild to moderate CAVS. 
 
Rationale.  Pro-inflammatory cytokines are significantly increased in patients with moderate 
or severe CAVS.  In experimental animals, interventions which reduce NO-sGC-cGMP 
signaling are known to significantly increase systemic inflammation in models of 
atherosclerosis and heart failure, and genetic or pharmacological interventions that increase 
NO-sGC-cGMP signaling in such models reduces local and systemic pro-inflammatory 
cytokine levels.  The effects of activating sGC on circulating inflammatory cytokines in 
CAVS are unknown.    
  
Goal: Determine whether long-term treatment with HMR1766 will result in sustained 
increases in systemic sGC signaling and reduce levels of circulating inflammatory cytokines 
in patients with mild to moderate CAVS.  This will be done using ELISA-based 
measurements of interleukin-6 and tumor necrosis factor α in venous blood samples.   
 
Quantitative criteria for success: 
Key outcomes: 
1) Quantiative outcomes: 
a. Change in levels of plasma interleukin-6 and plasma tumor necrosis factor 
α following 6 and 12months of treatment.    
i. Key comparisions will be between HMR1766-treated and placebo-
treated groups, where we will examine the change in inflammatory 
cytokine levels from baseline in subjects receiving HMR1766 or 
placebo capsules 
   
 
 

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Secondary Hypothesis/Outcome 2:  To determine whether HMR1766 will slow 
progression of aortic valve dysfunction in patients with mild to moderate CAVS.   
 
Rationale:  Progressive reductions in aortic valve area in CAVS are the result of progressive 
expansion of calcified lesions on the aortic valve.  Our preliminary findings in mice suggest 
that reducing osteogenic signaling in experimental animals can slow or halt accumulation of 
calcification in early stages of CAVS, and that these molecular and histological changes result 
in significant reductions in progression of aortic valve dysfunction.  Whether sGC activation 
with Ataciguat slows progression of aortic valve dysfunction in patients with CAVS, 
however, is unknown.   
 
Goal: Determine whether long-term treatment with HMR1766 will result in sustained 
increases in systemic sGC signaling slow progression of aortic valve dysfunction in patients 
with mild to moderate CAVS.  This will be done using echocardiography-based 
measurements of aortic valve function.   
   
Quantitative criteria for success: 
Key outcomes: 
1) Quantiative outcomes: 
a. Change in aortic valve function following 6 and 12 months of treatment.    
i. Key comparisions will be between HMR1766-treated and placebo-
treated groups, where we will examine the change in: 
1.  aortic valve area over time (calculated from the continuity 
equation) in subjects receiving HMR1766 or placebo 
capsules 
a. AVA will be evaluated by both the absolute value 
and following normalization for body surface area 
2. mean transvalvular pressure gradient over time (calculated 
from the blood velocity trace using the Bernoulli equation) 
in subjects receiving HMR1766 or placebo capsules 
 
 
 
 

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Tertiary Hypothesis/Outcome:  Ataciguat will slow progression of left ventricular 
dysfunction in patients with mild to moderate CAVS.    
 
Rationale:  Left ventricular dysfunction is a strong predictor of adverse events in patients 
with moderate to severe CAVS.  Increasing NO-sGC-cGMP signaling has been shown to slow 
deterioration of left ventricular function in experimental animal models of pressure overload 
(e.g., transverse aortic constriction), and may even reverse mild ventricular dysfunction when 
initiated in early stages of such models.  Whether activation of sGC by HMR1766 improves 
left ventricular function or slows progression of left ventricular dysfunction in patients with 
moderate CAVS is unknown.   
 
Goal: Determine whether long-term treatment with HMR1766 will result in sustained 
increases in systemic sGC signaling slow progression of aortic valve dysfunction in patients 
with mild to moderate CAVS.  This will be done using echocardiography-based 
measurements of aortic valve function.   
   
Quantitative criteria for success: 
Key outcomes: 
1) Quantitative outcomes:  
a. Change in left ventricular function following 6 and 12 of treatment.    
i. Key comparisions will be between HMR1766-treated and placebo-
treated groups, where we will examine the change in: 
1. Left ventricular systolic function (measured by 
echocardiographic measurement of left ventricular ejection 
fraction) 
2. Left ventricular diastolic function (measured using the E/A 
ratio derived from Doppler measurements) 
 
 
 
 
 

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3 
Study Design 
3.1 
General Design 
Study design. Patients will report to the Clinical Research and Trials Unit (CRTU) for 
tolerance testing. Patients will complete testing at one “baseline” visit and 2 “experimental” 
visits. In brief, patients will check in at the CRTU to have their height, weight and vital signs 
recorded. CRTU Nursing Staff will also perform a blood draw at this time. Patients will then 
lie quietly in a semi-recumbent position for 15 minutes, during which time baseline blood 
pressure will be measured using an automated blood pressure cuff around their upper arm to 
evaluate orthostatic tolerance.   Patients with symptomatic hypotension upon standing during 
the “baseline” visit will be excluded from further participation.  
 
Subjects will then undergo CT scanning (to evaluate aortic valve calcium levels), 
echocardiography (to evaluate aortic valve function and cardiac function), and DEXA 
scanning (to evaluate bone mineral density).  Subjects will have blood samples taken for 
baseline levels of pVASP239 levels and inflammatory cytokine levels.  Subjects who meet all 
inclusion criteria will then be randomized to one of two treatment arms: placebo or Ataciguat 
(200 mg/day). Subjects will self-administer Ataciguat or placebo at home each morning with 
food for the duration of 12 months. Standing tests (orthostatic tolerance testing), CT 
Scanning, Echocardiography, DEXA scanning, and blood sampling will be repeated at 6 
month intervals for the remainder of the study (12 minimum follow-up).     
 
PRE-CLINICAL HUMAN STUDIES 
Orthostatic tolerance 
Standing test: To determine whether patients experience orthostatic intolerance during a 
transition from a standardized, semi-recumbent position to a standing position, patients will be 
placed in a semi-recumbent position on an adjustable chair (45° torso incline, 10% thigh 
incline, with lower limbs/calves parallel to the floor) for 15 minutes, during which blood 
pressure will be measured non-invasively using automated sphygmomanometry devices 
placed on the patient’s upper arm (mean/steady-state blood pressure). Subjects will transition 
to a standing position at 15 minutes, allow for 2 minutes to elapse to reach a steady-state, and 
return to a semi-recumbent position.  If necessary (e.g., due to technical problems, etc.), this 
maneuver may be repeated 15 minutes later. Key outcomes are the perception of light-
headedness (i.e., symptomatic hypotension) and nadir blood pressures measured at the upper 
arm.  Our previous experience with this test is that it is highly reproducible and useful for 
detecting subjects who may have a high propensity for experiencing orthostatic intolerance.   
 
Echocardiography.  After enrollment in the study, patients will have a standard, clinical 
echocardiographic evaluation every 6 months to determine whether aortic valve or cardiac 
function changes over the course of the study.  This will include examination of cardiac 
function from short-axis, long-axis, apical 5-chamber, and parasternal views, as well as 
measurements/calculations of aortic valve area and mean transvalvular gradient.  While this 
procedure will be performed in theClinical Research and Trials Unit (CRTU), the procedure 
and subsequent measurements will be performed by a clinical sonographer employed by 
Mayo Clinic.  If enrollment in the study is greater than one month after the most recent 

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clinical echocardiogram, measurements of cardiac and aortic valve function will be repeated 
in the Clinical Research and Trials Unit (CRTU) for an optimal “baseline” measurement. 
 
Computed tomography (CT) scanning.  As described in detail previously, a standard, non-
contrast chest CT will be used to evaluate aortic valve calcium levels every 6 months 
throughout the study (minimum duration of enrollment = 12 months).   
 
Whole-body dual X-ray absorptiometry (DEXA) scanning.  Whole-body DEXA scanning 
will be used to evaluate changes in bone mineral density every 6 months to ensure that 
Ataciguat does not accelerate age-associated bone loss over the course of the study.  Changes 
in bone mineral density (or lack thereof) will be a core measurement evaluated by the DSMB 
every 6 months.  These measurements will be performed in the Clinical Research and Trials 
Unit (CRTU) at Mayo Clinic.   
 
Blood samples.  Venous blood samples (approximately 3 tablespoons) will be acquired from 
an antecubital vein at baseline and every 6 months thereafter for measurement of pro-
inflammatory cytokines, p-VASP239 levels, and NtBNP levels. We will also use this sample 
used to measure a number of markers of your general health and/or drug toxicity, including:  
 
 
• Hemoglobin, hematocrit, red blood cell levels, white blood cell levels, white blood cell 
count with differential platelet count.   
• Prothrombin time (PT), activated partial thromboplastin time (aPTT), international 
normalized ratio (INR)  
• Glucose, sodium, potassium, chloride, bicarbonate, calcium, phosphorus  
• Urea, serum creatinine, creatine phosphokinase, total cholesterol, low density 
lipoprotein levels, high density lipoprotein levels, triglycerides, total protein levels, 
bilirubin, alkaline phosphatase, lactate dehydrogenase, aspartate aminotransferase, 
alanine aminotransferase  
 
 
 
3.2 
Primary Study Endpoints 
The primary endpoint of this study relates to efficacy.  While we will document incidence of 
all adverse events resulting from ataciguat treatment in this study, our experimental visits 
focus primarily on detection of changes in aortic valve calcification and aortic valve function 
over time.   
 
3.3 
Primary Study Endpoints 
The primary endpoints of this study are:  
1) The change in aortic valve calcification over time (i.e., quantitative detection of 
changes in aortic valve calcification, which underlie subsequent changes in aortic 
valve function) 

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2) The change in systemic inflammation over time (i.e., quantitative detection of changes 
in circulating inflammatory cytokines).   
3) The change in aortic valve function over time (i.e., quantitative detection of the 
changes in aortic valve area and the mean transvalvular pressure gradient).  
4) The change in left ventricular function over time (i.e., quantitative detection of 
changes in left ventricular systolic and diastolic function) 
 
 

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4 Subject Selection Enrollment and Withdrawal 
Our aim is to identify patients with mild-to-moderate CAVS who have well-preserved left 
ventricular function (the predominance of patients seen clinically at our institution) and are 
hemodynamically stable.    
4.1 
Inclusion Criteria 
1. Age > 50 years 
2. Male or female sex 
3. Aortic valve area greater than 1.0 cm2 but less than 2.0 cm2  
4. Aortic valve calcium levels greater than 150 AU from chest CT 
5. Ejection fraction >50% 
4.2 
Exclusion Criteria 
1. Orthostatic intolerance or symptomatic hypotension prior to study or during study 
visits 
2. Positive pregnancy test during screening visit 
3. Nitrate use within 24 hours 
4. Systolic blood pressure <110 mm Hg 
5. Mean systemic arterial pressure <75 mm Hg 
6. Severe mitral or aortic regurgitation 
7. Retinal or optic nerve problems 
8. Recent (≤30 days) acute coronary syndrome 
9. Oxygen saturation <90% on room air 
10. Congenital valve disease 
11. Hepatic dysfunction/elevated liver enzymes 
12. Prescription of drugs known to alter NO-sGC-cGMP signaling (sildenafil, nitrates, etc.) 
13. Prescription of Warfarin (Coumadin) for chronic anticoagulation 
14. Concomitant participation in other trials at Mayo Clinic or elsewhere 
15. Use of phenytoin or related compounds for any indication 
16. Chronic midazolam treatment for any indication  
17. Use of monoamine oxidase inhibitors for any indication 
18. Use of anti-diabetic drugs in the sulfonylurea family  
19. Use of fluvastatin (predominantly degraded by CYP2C9) 
4.3 
Subject Recruitment, Enrollment and Screening 
Screening and selection of patients  
Patients will be identified by daily screening of results from the Mayo Clinic 
Echocardiography Laboratory.  As illustrated in Figure 1, study coordinators will identify 
patients meeting the criteria for moderate calcific aortic valve stenosis, and subsequently 
review the patient’s medical record for evidence of additional exclusion criteria.  Many 
patients with evidence of moderate calcific aortic valve disease are not referred for non-
contrast chest CT scanning—as such we will work with our clinical staff to review 
echocardiographic images from patients and select subjects with significant echogenicity on 
the aortic valve cusps (indicative of valvular calcium).   Our study coordinators will contact 

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these patients and schedule Visit #1 (which includes obtaining informed consent prior to CT 
scanning) to confirm that the subjects’ valvular calcium levels are >150 AU and that they are 
eligible for participation in the study.  Patients who receive a clinically-indicated CT scan and 
have evidence of valvular calcium levels >150 AU will not be required to undergo an 
additional CT scan as a part of Visit #1.   
 
 
Orthostatic tolerance testing  
Standing test: To determine whether patients experience orthostatic intolerance during a 
transition from a standardized, semi-recumbent position to a standing position, patients will be 
placed in a semi-recumbent position on an adjustable chair (45° torso incline, 10% thigh 
incline, with lower limbs/calves parallel to the floor) for 15 minutes, during which blood 
pressure will be measured non-invasively using automated sphygmomanometry devices 
placed on the patient’s upper arm (mean/steady-state blood pressure). Subjects will transition 
to a standing position at 15 minutes, allow for 2 minutes to elapse to reach a steady-state, and 
return to a semi-recumbent position. If necessary (e.g., due to technical problems, etc.), this 
maneuver may be repeated 15 minutes later. Key outcomes are the perception of light-
headedness (i.e., symptomatic hypotension) and nadir blood pressures measured at the upper 
arm.  This testing will be performed prior to the CT scan to ensure subject eligibility and 
minimize radiation exposure to potential subjects.    
 
4.4 
Early Withdrawal of Subjects 
There are three indications for early withdrawal of subjects: 
1) Individual subject participation will be terminated by the Principal Investigator if 
at any time the Principal Investigator feels there is a medical indication to do so 
(e.g., episode of syncope/symptomatic hypotension, adverse event that would 
compromise patient care/well-being, etc.).   
a. Subjects that experience orthostatic intolerance/symptomatic hypotension 
during the initial “baseline” tests (i.e., Visit 1) will be excluded from 
further participation in the study.    
2) Participation of all subjects will be terminated by the Principal Investigator if there 
is evidence that this pharmacological intervention unexpectedly accelerates 
progression of valve disease at any time point.  These interim evaluations will be 
performed by the statistician and the DSMB, and the Principal Investigator will 
remain blinded.    
3) At any point during the study, subjects retain the right to discontinue participation 
in the study.  Subjects can discontinue their participation by notifying the Principal 
Investigator or a study coordinator through a phone conversation, email 
communication, or in writing.  All contact information will be provided to subjects 
during the consent process.   
4.4.1 Data Collection and Follow-up for Withdrawn Subjects 
Data from subjects who elect to withdraw from this study for reasons unrelated to drug 
tolerance prior to the first follow-up visit (i.e., the 6 month time point) will be omitted from 
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valve calcification/aortic valve function/left ventricular function in patients with mild to 
moderate aortic valve stenosis, as both pre-and post-testing is critical for quantitatively 
determining efficacy of the compound.  For patients that withdraw due to an adverse 
event/side effect (or whose participation is terminated by a Principal Investigator for medical 
reasons), these data will be included in the calculation of proportion of patients who tolerate 
the drug.      
 
 
 

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5 Study Drug  
5.1 
Description 
The following drug product presentation is used in clinical trials: 
 
Capsules: Supplied for oral administration as soft capsules containing 50 mg of HMR1766 
(both calculated with reference to the active moiety) and the following excipients: macrogols, 
macrogolglycerol hydroxystearate, medium-chain partial glycerides, and glycerol. The soft 
capsule shell contains the following excipients: gelatin, glycerol, and the commercially 
available Anidrisorb 85/70 (contains sorbitol, sorbitan, mannitol, and higher polyols). The soft 
capsules are packaged in blister packs.  
 
Storage conditions and shelf life 
Capsules: Stability studies of Ataciguat soft capsules are in progress to confirm that, 
throughout the duration of the clinical studies, clinical supplies remain within the acceptance 
criteria defined in the specifications. Based on available stability data, the soft capsules are 
stable for at least 24 months when stored according to conditions specified in the clinical 
supplies’ labeling. As additional stability data become available, the shelf life may be 
extended. 
 
Adventitious agents safety evaluation 
Any animal- and/or human-derived material(s) used to manufacture the drug substance/drug 
product complies with the applicable BSE/TSE (Bovine Spongiform 
Encephalopathy/Transmissible Spongiform Encephalopathy) and viral safety regulations. 
5.2 
Treatment Regimen 
Ataciguat will be administered orally in 50 mg gelatin capsules packaged in aluminum blister 
packs.  A dose of 200 mg ataciguat or matching placebo (=4 capsules of 50 mg or matching 
placebo) will be given once daily in the morning, with food.  This dosing will be continued for 
the duration of the study (i.e., daily dosing for 12 months). Participants should take the study 
medication in the morning with food/breakfast, and the subject is expected to take their 
medication at their normal time on the days they come to the CRTU.      
5.3 
Method for Assigning Subjects to Treatment Groups 
Our industry partner (Sanofi) will provide us with pre-packaged boxes of Ataciguat or 
Placebo (each box containing sufficient capsules for 16 days of treatment at each dose).  
Subjects will be provided a 6 month supply of medication and will be given the additional 
medication as needed during interim or follow up visits.  The Mayo Research Pharmacist will 
work with our statistician for the randomization and blinding of the order in which Ataciguat 
or Placebo boxes will be given to enrolled patients.  A pharmacist from the Research 
Pharmacy at Mayo Clinic will give the supply of capsules to the CRTU nurse, who will 
subsequently bring the drug to each patient, confirm that the patient understands the risks and 
potential side effects associated with consuming the active compound (Ataciguat), and study 
team members will provide additional directions for taking the drug (i.e., with food, in the 
morning).     
 

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5.4 
Preparation and Administration of Study Drug 
Our industry partner, Sanofi, has prepared 50 mg gelatin capsules, packaged the capsules in 
aluminum blister packs, and will provide boxes which will contain 16 doses of the compound. 
Patients will be responsible for self-administration of the drug at home during the 6 month 
periods.   
 
 
5.5 
Subject Compliance Monitoring 
On day 7 of dosing, a study coordinator will call patients to confirm that: 
1) They are adhering to the treatment regimen for the study 
2) They have not experienced significant adverse side effects.   
A study coordinator will call patients every 30 days there-after, for the length of the study, to 
confirm that:  
1) They are adhering to the treatment regimen for the study 
2) They have not experienced significant adverse side effects.  
 
5.6 
Packaging 
Our industry partner, Sanofi, has prepared 50 mg gelatin capsules, packaged the capsules in 
aluminum blister packs, and will provide numbered wallets which will contain 16 doses of the 
compound or 16 doses of placebo capsules.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
5.7 
Masking/Blinding of Study  
Randomization will be done through a website and maintenance of the blind for the study will 
be the responsibility of the study team in cooperation with the Mayo Clinic Research 
Pharmacy according to the SOPs established. 

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5.8 
Receiving, Storage, Dispensing and Return of study drug 
Pre-packaged Ataciguat and Placebo capsules will be shipped from Sanofi to the Mayo Clinic 
Research Pharmacy, stored in a secure location within the research pharmacy between +2°C 
and +25°C, and protected from light.  Both Ataciguat and Placebo will be stored in the 
original package.  Each box containing Ataciguat or Placebo will be dispensed from the 
Research Pharmacy to the subject enrolled in the study, and at the completion of the study, 
subjects will return any unused compound to the Research Pharmacy. 
 
 
5.8.1 Return or Destruction of Study Drug 
At the completion of the study, there will be a final reconciliation of drug shipped, drug 
dispensed, drug returns, and drug remaining.  This reconciliation will be logged on the drug 
reconciliation form, signed and dated.  Any discrepancies noted will be documented and 
investigated, prior to return or destruction of unused study drug.  Drug destroyed on site will 
be documented in the study files. 
 
 
 
 
 

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OVERALL TIMELINE OF STUDY 
 
 
Day 
Screening
/Consent 
            
Days        
1-360 
Day    
7 
Day     
30 
Day 
60 
Day    
90 
Day     
120 
Day 
150 
Day 
180 
Days 
210/240/
270/300/
330 
Day 
360 
 
 
 
Month 
0 
 
 
1 
2 
3 
4 
5 
6 
variable 
12 
 
 
Study Activity 
Visit 1 
 
Drug 
Treatment 
(at home) 
Follow 
up 
Follow 
up 
Follow 
up 
Follow 
up 
Follow 
up 
Follow 
up 
Visit 
2 
Follow 
up 
Visit    
3 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
History 
X 
 
 
 
 
 
 
 
X 
 
X 
 
Physical exam  
(Ht, Wt, BSA, VS) 
X 
 
 
 
 
 
 
 
X 
 
X 
 
Drug Treatment 
 
X 
 
 
 
 
 
 
 
 
 
 
CT 
Scanning 
for 
valvular
calcium levels 
X 
 
 
 
 
 
 
 
X 
 
X 
 
Echocardiography for 
valvular/ventricular function 
X 
 
 
 
 
 
 
 
X 
 
X 
 
Blood sample for  
p-VASP239 and other clinical
blood/biomarker testing 
X 
 
 
 
 
 
 
 
X 
 
X 
 
DEXA 
scanning 
for 
bone
mineral density 
X 
 
 
 
 
 
 
 
X 
 
X 
 
Orthostatic Tolerance Testing 
X 
 
 
 
 
 
 
 
X 
 
X 
 
POC Pregnancy testing 
X 
 
 
 
 
 
 
 
 
 
 
 
History over the phone 
X 
 
X 
X 
X 
X 
X 
X 
 
X 
 
 
Phone follow-up for adverse
events 
 
 
X 
X 
X 
X 
X 
X 
 
X 
 
 
 

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Summary of study/approach 
 
Subjects will be identified from patients undergoing echocardiographic evaluation of aortic valve 
function for suspected calcific aortic valve disease at Mayo Clinic in Rochester, MN.  Subjects 
who have mild/moderate aortic valve stenosis (aortic valve area greater than1.0 cm2 but less than 
2.0 cm2 and valve calcium levels >150 AU from a chest CT scan) will be enrolled for 
participation in this study.  The general design of the current study is a randomized, double-
blinded, placebo-controlled protocol, in which patients will receive 200 mg per day of 
Ataciguat/HMR1766 for 12 months.  Orthostatic tolerance, aortic valve calcium levels, aortic 
valve function, left ventricular function, bone mineral density, and markers of drug 
efficacy/treatment compliance will be measured pre- and post-treatment.  

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6 METHODS 
General overview of visits 
6.1 
Screening and selection of patients 
Patients will be identified by daily screening of results from the Mayo Clinic Echocardiography 
Laboratory.  As illustrated in Figure 1, study coordinators will identify patients meeting the 
criteria for moderate calcific aortic valve stenosis, and subsequently review the patient’s medical 
record for evidence of additional exclusion criteria.  Many patients with evidence of moderate 
calcific aortic valve disease are not referred for non-contrast chest CT scanning—as such we will 
work with our clinical staff to review echocardiographic images from patients and select subjects 
with significant echogenicity on the aortic valve cusps (indicative of valvular calcium).   Our 
study coordinators will contact these patients and schedule Visit #1 (which includes obtaining 
informed consent prior to CT scanning) to confirm that the subjects’ valvular calcium levels are 
>150 AU and that they are eligible for participation in the study.  Patients who receive a 
clinically-indicated CT scan and have evidence of valvular calcium levels >150 AU will not be 
required to undergo an additional CT scan as a part of Visit #1.    
 
Key Inclusion Criteria 
Key Exclusion Criteria 
• 
Age > 50 years 
• 
Male or female sex 
• 
Aortic valve area greater than 1.0 cm2 but less 
than 2.0 cm2  
• 
Aortic valve calcium levels greater than 150 
AU from chest CT 
• 
Ejection fraction >50% 
 
• 
history of orthostatic intolerance or 
symptomatic hypotension 
• 
Positive Pregnancy Test 
• 
nitrate use within 24 hours 
• 
systolic blood pressure <110 mm Hg, mean 
systemic arterial pressure <75 mm Hg 
• 
severe mitral or aortic regurgitation 
• 
 retinal or optic nerve problems 
• 
recent (≤30 days) acute coronary syndrome 
• 
oxygen saturation <90% on room air 
• 
history/recent evidence of hepatic dysfunction 
from clinical record/blood testing 
• 
congenital valve disease 
• 
Hepatic Dysfunction/Elevated Liver Enzymes 
• 
prescription of drugs known to alter nitric oxide 
signaling (e.g., sildenafil, nitrates, etc.) 
• 
prescription of warfarin (coumadin) for chronic 
anticoagulation 
• 
concomitant participation in other trials at 
Mayo Clinic or elsewhere 
• 
use of phenytoin or related compounds for any 
indication 
• 
chronic midazolam treatment for any indication  
• 
use of monoamine oxidase inhibitors for any 
indication 

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• 
use of anti-diabetic drugs in the sulfonylurea 
class 
• 
Use of fluvastatin (predominantly metabolized 
by CYP2C9) 
After agreeing to participate in the study, subjects will report to the Clinical Research and Trials 
Unit (CRTU) for completion of Visit 1 (informed consent, confirmation of eligibility/review of 
medical history, physical examination/pre-screening to ensure subject does not have physical 
disabilities that would preclude completion of tolerance testing, etc.).  At the end of Visit 1, 
subjects will schedule the follow-up visits for this study (i.e., experimental Visits 2 and 3).   
 
 

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Procedures for orthostatic tolerance testing (Visits 1, 2, and 3) 
Standing test: To determine whether patients experience orthostatic intolerance during a 
transition from a standardized, semi-recumbent position to a standing position, patients will be 
placed in a semi-recumbent position on an adjustable chair (45° torso incline, 10% thigh incline, 
with lower limbs/calves parallel to the floor) for 15 minutes, during which blood pressure will be 
measured non-invasively using automated sphygmomanometry devices placed on the patient’s 
upper arm (mean/steady-state blood pressure). Subjects will transition to a standing position at 15 
minutes, allow for 2 minutes to elapse to reach a steady-state, and return to a semi-recumbent 
position.  Key outcomes are the perception of light-headedness (i.e., symptomatic hypotension) 
and nadir blood pressures measured at the upper arm.  This testing will be performed prior to the 
CT scan to ensure subject eligibility and minimize radiation exposure to potential subjects.    
 
Flow of protocol and key blood pressure (BP) measurement points: 
 
 
 
 
 
BP 
 
 
BP 
 
BP 
Time 
15 minutes 
2 minutes 
Event 
Acclimatization/ 
stabilization 
while sitting 
Standing test 
6.2 
Overview of Visit 1 
The purpose of Visit 1 is three-fold:  
1) to confirm that patients do not experience orthostatic hypotension during any of the 
tests, which would preclude further participation in the study.   
2) to confirm that subjects meet inclusion criteria for minimum valvular calcium levels 
via CT scanning and document baseline valvular calcium levels 
3) to collect baseline data for valvular function, ventricular function, biomarker 
levels/inflammatory state, and bone mineral density prior to randomization to drug- or 
placebo-treated groups.    
 
Admit to 
Clinical 
Research 
Unit/Acquire 
Blood Sample 
Acclimatization 
to semi-
recumbent 
position and 
subsequent 
“standing” test 
CT Scan to 
evaluate aortic 
valve calcium 
levels 
Echocardiography 
to evaluate aortic 
valve function 
and left 
ventricular 
function 
DEXA scan to 
evaluate bone 
mineral density 
Receive drug supply 
and directions for 
usage/administration 
and subsequent 
discharge 
30 minutes 
~45 minutes 
~1 hour 
~1 hour 
45 minutes 
2 hours 
 
Monitoring BP 
with automated 
arm cuff  
 
 
Monitoring BP and 
ECG changes every 
30 minutes 
 

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6.3 
Overview of Visit 2 
The purpose of Visit 2 is three-fold:  
1) to confirm that patients do not experience newly documented orthostatic hypotension 
during any of the tests, which would warrant medical consultation and potential 
exclusion from participation in the study.      
2) To document changes in aortic valve calcification following 6 months of treatment 
with either placebo or Ataciguat.   
3) to determine whether there are changes in valvular function, ventricular function, 
biomarker levels/inflammatory state, and bone mineral density following 6 months of 
treatment with either placebo or Ataciguat.    
 
 
Admit to 
Clinical 
Research 
Unit/Acquire 
Blood Sample 
Acclimatization 
to semi-
recumbent 
position and 
subsequent 
“standing” test 
CT Scan to 
evaluate aortic 
valve calcium 
levels 
Echocardiography 
to evaluate aortic 
valve function 
and left 
ventricular 
function 
DEXA scan to 
evaluate bone 
mineral density 
Receive drug supply 
and directions for 
usage/administration 
and subsequent 
discharge 
30 minutes 
~45 minutes 
~1 hour 
~1 hour 
45 minutes 
30 minutes 
 
Monitoring BP 
with automated 
arm cuff  
 
 
 
 
 
 

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6.4 
Overview of Visit 3 
The purpose of Visit 3 is three-fold:  
1) to confirm that patients do not experience newly documented orthostatic hypotension 
during any of the tests, which would warrant medical consultation and potential 
exclusion from participation in the study.      
2) To document changes in aortic valve calcification following 12 months of treatment 
with either placebo or Ataciguat.   
3) to determine whether there are changes in valvular function, ventricular function, 
biomarker levels/inflammatory state, and bone mineral density following 12 months of 
treatment with either placebo or Ataciguat.    
 
 
Admit to 
Clinical 
Research 
Unit/Acquire 
Blood Sample 
Acclimatization 
to semi-
recumbent 
position and 
subsequent 
“standing” test 
CT Scan to 
evaluate aortic 
valve calcium 
levels 
Echocardiography 
to evaluate aortic 
valve function 
and left 
ventricular 
function 
DEXA scan to 
evaluate bone 
mineral density 
Return any left-over 
study 
medication/discharge 
30 minutes 
~45 minutes 
~1 hour 
~1 hour 
45 minutes 
30 minutes 
 
Monitoring BP 
with automated 
arm cuff  
 
 
 
 
 
 
 
 

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7 Statistical Plan 
The primary endpoint will be change in aortic valve calcification as assessed by computed 
tomography scanning.  Secondary and tertiary endpoints are changes in valvular function, 
ventricular function, biomarker levels/inflammatory state, and bone mineral density following 
12months of treatment with either placebo or Ataciguat.   
7.1 
Primary Hypothesis 
Our primary hypothesis is:  
1) Ataciguat will increase systemic sGC signaling and halt accumulation of aortic valve 
calcium in patients with mild to moderate CAVS.   
7.2 
Secondary Hypotheses 
 Our secondary hypotheses are: 
1) Ataciguat will reduce levels of circulating inflammatory cytokines in patients with 
mild to moderate CAVS. 
2) Ataciguat will slow progression of aortic valve dysfunction in patients with mild to 
moderate CAVS 
7.3 
Tertiary Hypothesis 
Our tertiary hypothesis is:  
1) Ataciguat will slow progression of left ventricular dysfunction in patients with mild to 
moderate CAVS 
7.4 
Subject Population for Analysis 
The primary study evaluation will be an intent-to-treat (ITT) analysis. We will only perform 
statistical analyses on subjects that are randomized to treatment (they complete the baseline 
assessment and are not found to have orthostatic hypotension),  and completed at least one post-
treatment session. Subjects who do not complete at least one post-treatment session (orthostatic 
intolerance/adverse side effects, etc.) will not be included in the analysis. . We will also do a per 
protocol analysis. This patient population will consist of patients who were compliant with the 
treatment they received (even if it was not the treatment to which they were randomized). 
Compliance will be determined by self report and capsule blister pack counting at the end of the 
treatment period. To be included in the per-protocol analysis, patients need to be at least 60% or 
more compliant. 
7.5 Sample size 
This is a double-blinded, randomized, placebo-controlled study to determine whether Ataciguat 
administered at a dose of 200 mg/day effectively slows progression of aortic valve calcification in 
patients with mild-to-moderate CAVD.  The intended analysis will be to compare the change in 
aortic valve calcium from baseline between the control group and the treatment group. A sample 
size of 50 in each group will have 80% power to detect an effect size of 0.57 using a two group t-
test with a 0.05 two-sided significance level. The effect being compared between the two groups 
is the mean change in aortic valve calcium levels at 12 months (12 month aortic valve calcium 
level – baseline aortic valve calcium level). The effect size is the expected difference in the mean 
change from baseline between the two groups) divided by the within-group standard deviation of 

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the change from baseline. It is felt that for this drug to be of clinical interest in treating aortic 
value calcification, there would need to be a effect size of 0.50-0.60 standard deviations or more 
(i.e. moderate to large effect). A sample size of 100 patients (50 in each group) provides adequate 
power (80%) to detect such a difference at the 12 month time point (i.e., our minimum treatment 
duration).  
 
7.6 Analysis 
. 
The primary analysis will be an intent-to-treat analysis where all randomized patients who 
underwent at least one post-treatment evaluation (e.g. at 6 months or 12 months); patients will be 
analyzed according to the treatment to which they were randomized. The continuous outcomes 
will be analysed with a mixed effects model to account for the correlation of measurements within 
the same patient. The effect of interest for the primary analysis is to determine whether the change 
in aortic valve calcium levels is the same between the control group (patient receiving placebo)  
and the treated group (patients receiving Ataciguat). An unstructured covariance matrix will be 
used in the analysis.A mixed effects model will also be used to evaluate the secondary and tertiary 
quantitative endpoints. 
 
Secondary analysis will be on a per-protocol level where the patients included are those who were 
compliant with the treatment that they received. There will also be exploratory analyses done with 
respect to subgroups of patients (e.g. by gender) as well as any evaluation of patient/disease 
characterisitcs that are associated with changes in the endpoints. 
8 Safety and Adverse Events 
 
8.1 
Definitions 
Unanticipated Problems Involving Risk to Subjects or Others (UPIRTSO) 
Any unanticipated problem or adverse event that meets the following three criteria:  
• Serious: Serious problems or events that result in significant harm, (which may be 
physical, psychological, financial, social, economic, or legal) or increased risk for the 
subject or others (including individuals who are not research subjects). These include: (1) 
death; (2) life threatening adverse experience; (3) hospitalization - inpatient, new, or 
prolonged; (4) disability/incapacity - persistent or significant; (5) birth defect/anomaly; (6) 
breach of confidentiality and (7) other problems, events, or new information (i.e. 
publications, DSMB reports, interim findings, product labeling change) that in the opinion 
of the local investigator may adversely affect the rights, safety, or welfare of the subjects or 
others, or substantially compromise the research data, AND 
• Unanticipated: (i.e. unexpected) problems or events are those that are not already described 
as potential risks in the protocol, consent document, not listed in the Investigator’s 
Brochure, or not part of an underlying disease. A problem or event is "unanticipated" when 
it was unforeseeable at the time of its occurrence. A problem or event is "unanticipated" 
when it occurs at an increased frequency or at an increased severity than expected, AND 
• Related: A problem or event is "related" if it is possibly related to the research procedures. 

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Adverse Event 
An untoward or undesirable experience associated with the use of a medical product (i.e. drug, 
device, biologic) in a patient or research subject. 
Serious Adverse Event 
Adverse events are classified as serious or non-serious.  Serious problems/events can be well 
defined and include; 
• death 
• life threatening adverse experience 
• hospitalization 
• inpatient, new, or prolonged; disability/incapacity 
• persistent or significant birth defect/anomaly 
 
and/or per protocol may be problems/events that in the opinion of the sponsor-investigator 
may have adversely affected the rights, safety, or welfare of the subjects or others, or 
substantially compromised the research data. 
 
All adverse events that do not meet any of the criteria for serious, should be regarded as non-
serious adverse events.  
 
Adverse Event Reporting Period 
 
 
Preexisting Condition 
A preexisting condition is one that is present at the start of the study.  A preexisting condition 
should be recorded as an adverse event if the frequency, intensity, or the character of the 
condition worsens during the study period. 
 
General Physical Examination Findings 
At screening, any clinically significant abnormality should be recorded as a preexisting condition.  
At the end of the study, any new clinically significant findings/abnormalities that meet the 
definition of an adverse event must also be recorded and documented as an adverse event.  
 
Post-study Adverse Event 
All unresolved adverse events should be followed by the sponsor-investigator until the events are 
resolved, the subject is lost to follow-up, or the adverse event is otherwise explained.  At the last 
scheduled visit, the sponsor-investigator should instruct each subject to report, to the sponsor-
investigator, any subsequent event(s) that the subject, or the subject’s personal physician, believes 
might reasonably be related to participation in this study.  
 
Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization should be 
documented and reported as a serious adverse event unless specifically instructed otherwise in 

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this protocol.  Any condition responsible for surgery should be documented as an adverse event if 
the condition meets the criteria for an adverse event.  
 
8.2 
Recording of Adverse Events 
At each contact with the subject, the study team must seek information on adverse events by 
specific questioning and, as appropriate, by examination.  Information on all adverse events 
should be recorded immediately in the source document, and also in the appropriate adverse event 
section of the case report form (CRF).  All clearly related signs, symptoms, and abnormal 
diagnostic, laboratory or procedure results should be recorded in the source document. 
 
All adverse events occurring during the study period must be recorded.  The clinical course of 
each event should be followed until resolution, stabilization, or until it has been ultimately 
determined that the study treatment or participation is not the probable cause.  Serious adverse 
events that are still ongoing at the end of the study period must be followed up, to determine the 
final outcome.  Any serious adverse event that occurs after the study period and is considered to 
be at least possibly related to the study treatment or study participation should be recorded and 
reported immediately. 
8.3 
Reporting of Serious Adverse Events and Unanticipated Problems 
When an adverse event has been identified, the study team will take appropriated action necessary 
to protect the study participant and then complete the Study Adverse Event Worksheet and log.  
The sponsor-investigator will evaluate the event and determine the necessary follow-up and 
reporting required. 
8.3.1 Sponsor-Investigator reporting: notifying the Mayo IRB 
The sponsor-investigator will report to the Mayo IRB any UPIRTSOs and Non-UPIRTSOs 
according to the Mayo IRB and the Data Safety Monitoring Board providing oversight for the 
study.   
8.3.2 Sponsor-Investigator reporting: Notifying the FDA 
The sponsor-investigator will report to the FDA all unexpected, serious suspected adverse 
reactions according to the required IND Safety Reporting timelines, formats and requirements. 
 
Unexpected fatal or life threatening suspected adverse reactions where there is evidence to 
suggest a causal relationship between the study drug/placebo and the adverse event, will be 
reported as a serious suspected adverse reaction.  This will be reported to the FDA on FDA Form 
3500A, no later than 7 calendar days after the sponsor-investigator’s initial receipt of the 
information about the event. 
 
Other unexpected serious suspected adverse reactions where there is evidence to suggest a causal 
relationship between the study drug/placebo and the adverse event, will be reported as a serious 
suspected adverse reaction.  This will be reported to the FDA on FDA Form 3500A, no later than 
15 calendar days after the sponsor-investigator’s initial receipt of the information about the event. 
 

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Any clinically important increase in the rate of serious suspected adverse reactions over those 
listed in the protocol or product insert will be reported as a serious suspected adverse reaction.  
This will be reported to the FDA on FDA Form 3500A no later than 15 calendar days after the 
sponsor-investigator’s initial receipt of the information about the event. 
 
Findings from other studies in human or animals that suggest a significant risk in humans exposed 
to the drug will be reported.  This will be reported to the FDA on FDA Form 3500A, no later than 
15 calendar days after the sponsor-investigators initial receipt of the information about the event. 
 
8.4 
Unblinding Procedures 
 
Following the completion of the first 25 patients in each arm at each time point (i.e., 25 placebo, 
25 Ataciguat), we will count the total number non-tolerated adverse events and/or physiological 
changes indicating discontinuation of treatment due to patient safety.  Our statistician will present 
the unblinded data to our Data Safety Monitoring Board (DSMB) for evaluation.  Depending 
upon the number and magnitude of adverse events/adverse physiological changes in each group, 
we will abide by the recommendation of the DSMB to continue or discontinue the study.   
 
In the unlikely event that there is a significant, unexpected, severe adverse event (e.g., myocardial 
infarction, sudden deterioration in clinical status, or death), we will immediately unblind 
investigators to determine whether the event was associated with Ataciguat treatment.  In this 
unlikely event, we would also immediately report the event to our IRB, DSMB, and to NIH.   
8.5 
Stopping Rules  
 
As noted in previous sections, we will stop these studies prematurely if: 
1) There is evidence that patients will not tolerate the given dose of the drug (e.g., >30% 
of patients experiencing symptomatic/orthostatic hypotension following 6 months of 
treatment with Ataciguat).   
2) There are serious/unexpected side effects in patients receiving Ataciguat.   
 
8.6 
Medical Monitoring 
It is the responsibility of the Principal Investigator to oversee the safety of the study at his/her 
site.  This safety monitoring will include careful assessment and appropriate reporting of adverse 
events as noted above, as well as the construction and implementation of a site data and safety-
monitoring plan (see section 10  “Study Monitoring, Auditing, and Inspecting”).  Medical 
monitoring will include a regular assessment of the number and type of serious adverse events.  
Maurice Enriquez-Sarano, MD, is a cardiologist and Co-Principal Investigator in this study, has 
extensive experience in the medical management of this population, and will be providing regular 
medical oversight for this study.   
8.6.1 Internal Data and Safety Monitoring Board 
 

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We have established an internal DSMB to provide oversight for this study.  Membership of the 
DSMB is comprised of a minimum of five individuals from Mayo Clinic Rochester and includes; 
- The chair of the DSMB (voting member), chosen from the physician representatives 
- Additional three (3) or more physician representatives (voting members) 
- Biostatistician representative (voting member) 
- Representative from the Surgical Clinical Research Office (voting member) 
- Ad hoc members from the Division of Cardiovascular Diseases at Mayo Clinic to be 
appointed to the committee by the chair for study-specific expertise.   
 
The DSMB will meet at key decision points in the study, which include: 
1) After 50 patients (25 patients per arm) complete Visit #2 (i.e., the first follow-up visit 
to evaluate changes in aortic valve calcification, aortic valve function, cytokine levels, 
and left ventricular function), unblinded data will be provided to the DSMB to 
determine whether there are any adverse physiological effects of the drug during the 
first 6 months of treatment.   
2) After 50 patients (25 patients per arm) complete Visit #3 (i.e., the one year follow-up 
visit to evaluate changes in aortic valve calcification, aortic valve function, cytokine 
levels, and left ventricular function), unblinded data will be provided to the DSMB to 
determine whether there are any adverse physiological effects of the drug during the 
first 12 months of treatment.   
3) At interim points, if necessary, when there is sufficient evidence suggesting that 
Ataciguat may elicit severe adverse events and/or have a poor tolerance profile in this 
patient population.  
 
 
9 Data Handling and Record Keeping 
9.1 
Confidentiality 
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  
Those regulations require a signed subject authorization informing the subject of the following:  
• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of their PHI.  
In the event that a subject revokes authorization to collect or use PHI, the investigator, by 
regulation, retains the ability to use all information collected prior to the revocation of subject 
authorization.  For subjects that have revoked authorization to collect or use PHI, attempts should 
be made to obtain permission to collect at least vital status (long term survival status that the 
subject is alive) at the end of their scheduled study period.  As clearly stated in the consent form, 
clincially-relevant information collected as a part of this study (e.g., blood testing results, results 
from echocardiographic testing, and results from CT scanning tests) will be added to the subject’s 
medical record.   

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9.2 
Source Documents 
Source data is all information, original records of clinical findings, observations, or other 
activities in a clinical trial necessary for the reconstruction and evaluation of the trial.  Source data 
are contained in source documents.  Examples of these original documents, and data records 
include: hospital records, clinical and office charts, laboratory notes, memoranda, subjects’ diaries 
or evaluation checklists, pharmacy dispensing records, recorded data from automated instruments, 
copies or transcriptions certified after verification as being accurate and complete, microfiches, 
photographic negatives, microfilm or magnetic media, x-rays, subject files, and records kept at the 
pharmacy, at the laboratories, and at medico-technical departments involved in the clinical trial. 
9.3 
Case Report Forms 
 
Data Management 
Initial data used for screening potential subjects will be derived from the electronic medical 
record and entered into electronic case report forms within Medidata Rave (a software package 
endorsed by Mayo Clinic’s Clinical Trial Management System).  Data collected on paper case 
report forms during screening visits (e.g., height, weight) will be transferred to electronic case 
report forms at the end of each session.   
 
Data Processing 
We will transcribe or directly enter subject source data into eCRFs using Medidata Rave at the 
time of or as soon as possible after the subject visit. All completed eCRFs will be reviewed by the 
study coordinator at regular intervals as the study progresses.    
 
Data Security and Confidentiality 
 
Database and Web servers will be secured through controlled physical access. For security 
reasons, and in compliance with regulatory guidelines of Medidata Rave, system access is granted 
to the user who owns the sign on identification and password in use.  Access codes are non-
transferrable. Site personnel who have not undergone training may not access the study eCRF’s 
until appropriate training is completed and documented.  The eCRF data elements do not reside 
on the users work station; they are transmitted to a secure central database (host site) as forms are 
completed or updated. Protocol-specified source documents (e.g. hospital discharge summaries, 
operative/procedural reports) will be retrieved as necessary.  Copies of all study-related 
documentation will be retained at the site. 
 
 
Data Quality Assurance/Clarification Process 
 
The CTMS Medidata Rave database will have consistency checks programmed into the system to 
inform investigators of potential data issues as the data entry progresses.  The exception log for 
entries will be reviewed by the study coordinator/monitor to identify potential training and/or data 
integrity issues.  If data integrity issues are suspected, the study coordinator/monitor will perform 
site monitoring, including review of the eCRFs with verification to the source documentation. 
During monitoring visits, the site will make their computer and/or high speed internet access 

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available to the study coordinator/monitor so that he or she may verify the data entries with the 
source documentation.  
9.4 
Records Retention 
The sponsor-investigator will retain the specified records and reports for; 
1. Up to 2 years after the marketing application is approved for the drug; or, if a marketing 
application is not submitted or approved for the drug, until 2 years after shipment and 
delivery of the drug for investigational use is discontinued and the FDA has been so 
notified. OR 
2. As outlined in the Mayo Clinic Research Policy Manual –“Access to and Retention of 
Research Data Policy” http://mayocontent.mayo.edu/research-policy/MSS_669717   
Whichever is longer. 
 
 
 

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10 Study Monitoring, Auditing, and Inspecting 
10.1 Study Monitoring Plan 
 
The investigator will allocate adequate time for such monitoring activities.  The Investigator will 
also ensure that the monitor or other compliance or quality assurance reviewer is given access to 
all the study-related documents and study related facilities (e.g. pharmacy, diagnostic laboratory, 
etc.), and has adequate space to conduct the monitoring visit. 
 
10.2 Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the IRB, the 
sponsor, and government regulatory agencies, of all study related documents (e.g. source 
documents, regulatory documents, data collection instruments, study data etc.).  The investigator 
will ensure the capability for inspections of applicable study-related facilities (e.g. pharmacy, 
diagnostic laboratory, etc.). 
 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable compliance offices. 
11 Ethical Considerations 
This study is to be conducted according to United States government regulations and Institutional 
research policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted local Institutional 
Review Board (IRB), in agreement with local legal prescriptions, for formal approval of the 
study.  The decision of the IRB concerning the conduct of the study will be made in writing to the 
sponsor-investigator before commencement of this study. 
 
All subjects for this study will be provided a consent form describing this study and providing 
sufficient information for subjects to make an informed decision about their participation in this 
study.  This consent form will be submitted with the protocol for review and approval by the IRB 
for the study.  The formal consent of a subject, using the Approved IRB consent form, must be 
obtained before that subject undergoes any study procedure.  The consent form must be signed by 
the subject or the subject’s legally authorized representative, and the individual obtaining the 
informed consent. 
 
12 Study Finances 
12.1 Funding Source 
This study is supported by National Institutes of Health Grant TR000954 (administered through 
the National Center for Accelerating Translational Sciences).   

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12.2 Conflict of Interest 
Dr. Jordan D. Miller and Dr. Bin Zhang hold a provisional patent for harnessing sGC signaling to 
slow progression of calcification in humans with aortic valve stenosis.  Drs. Miller and Zhang 
currently do not receive licensing royalties from these studies, but may at some point in the 
future.    
 
12.3 Subject Stipends or Payments 
 
Subjects will receive $125 upon completion of each experimental session (i.e., Visits 1, 2 and 3), 
for a total possible compensation of $375.  This remuneration is for time and inconvenience, and 
is not based on risk or invasiveness of the proposed studies.  Subjects will also be reimbursed for 
travel if they reside outside of Rochester, MN or its immediately surrounding communities.    
13 Publication Plan 
Data from these studies will be presented at national scientific meetings in the form of an abstract 
(which is frequently published as well), and will ultimately be published in a peer-reviewed 
scientific journal.   
 
 
 
 
 
 

Long-term efficacy of Ataciguat in Patients with Moderate CAVS 
Version 5 
Miller 14-006469 Protocol.docx 
 
Revised 3/23/2015 
Page 43 of 43 
Jordan D. Miller, PhD 
 
CONFIDENTIAL 
 
 
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