A Randomized, Subject and Investigator-blind, Placebo-controlled Study of CLR325 in Chronic Stable Heart Failure Patients
Phase: PHASE2
Conditions: Chronic Stable Heart Failure
Sponsor: Novartis Pharmaceuticals

Novartis Institutes for BioMedical Research
CLR325
Clinical Trial Protocol CCLR325X2202
A randomized, subject and investigator-blind, 
placebo-controlled study of CLR325 in 
chronic stable heart failure patients
Document type:
Amended Protocol Version
EUDRACT number:
2016-001387-12
Version number:
v05 (Clean)
Development phase:
IIa
Release date:
27-Aug-2018
Property of Novartis
Confidential
May not be used, divulged, published, or otherwise disclosed
without the consent of Novartis

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Site Operations Manual (SOM)
A Site Operations Manual (SOM) accompanies this protocol, providing the operational details 
for study conduct.
Notification of serious adverse events
Refer to Section 9.2 of the protocol for definitions and reporting requirements for Serious 
Adverse Events (within 24 hours after awareness of the SAE to the local Novartis Chief 
Medical Office and Patient Safety (CMO & PS) Department and notify the Study Lead).
Contact information is listed in the Site Operations Manual.

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Table of contents
Site Operations Manual (SOM)...........................................................................................2
Notification of serious adverse events.................................................................................2
Table of contents .................................................................................................................3
List of tables ........................................................................................................................6
List of figures ......................................................................................................................6
List of abbreviations............................................................................................................7
Pharmacokinetic definitions and symbols...........................................................................9
Amendment 5 (August 2018)............................................................................................10
Amendment 4 (October 2017)...........................................................................................12
Amendment 3 (February 2017) .........................................................................................14
Amendment 2 (Aug 2016).................................................................................................15
Amendment 1 (April 2016) ...............................................................................................16
Protocol synopsis...............................................................................................................18
1
Introduction .......................................................................................................................20
1.1
Background............................................................................................................20
1.2
Study purpose ........................................................................................................23
2
Study objectives.................................................................................................................24
2.1
Primary objective(s)...............................................................................................24
2.2
Secondary objective(s)...........................................................................................24
3
Investigational plan ...........................................................................................................25
3.1
Study design...........................................................................................................25
3.4
Rationale for choice of comparator .......................................................................29
3.6
Risks and benefits..................................................................................................29
3.6.1
Potential risks associated with blood collection....................................30
3.6.2
Potential risks associated with immunogenicity ...................................31
3.6.3
Potential risks associated with infusion-related reactions.....................31
3.6.4
Potential risks associated with systemic inflammation.........................31
3.6.5
Potential risks associated with a PA catheter........................................32
4
Population..........................................................................................................................32
4.1
Inclusion criteria ....................................................................................................32
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4.2
Exclusion criteria...................................................................................................33
5
Restrictions for Study Subjects .........................................................................................34
5.1
Contraception requirements...................................................................................34
5.2
Prohibited treatment...............................................................................................34
5.3
Dietary restrictions and smoking...........................................................................34
5.4
General restrictions................................................................................................34
6
Treatment...........................................................................................................................35
6.1
Study treatment......................................................................................................35
6.1.1
Investigational treatment.......................................................................35
6.2
Treatment arms......................................................................................................35
6.3
Permitted dose adjustments and interruptions of study treatment.........................35
6.4
Treatment assignment............................................................................................35
6.5
Treatment blinding.................................................................................................36
6.6
Emergency breaking of assigned treatment code ..................................................36
6.7
Treatment exposure and compliance .....................................................................37
6.8
Recommended treatment of adverse events ..........................................................37
6.9
Rescue medication.................................................................................................37
6.10
Concomitant treatment...........................................................................................37
7
Discontinuation and study completion ..............................................................................37
7.1
Discontinuation of study treatment........................................................................37
7.2
Study completion and post-study treatment ..........................................................39
7.2.1
Lost to follow-up...................................................................................39
7.3
Withdrawal of consent...........................................................................................39
7.4
Study Stopping rules..............................................................................................40
7.5
Early study termination..........................................................................................40
8
Procedures and assessments ..............................................................................................41
8.1
Informed consent procedures.................................................................................45
8.2
Subject demographics/other baseline characteristics.............................................45
8.3
Efficacy / Pharmacodynamics ...............................................................................46
8.3.2
Invasive hemodynamic monitoring.......................................................46
8.3.3
Echocardiogram ....................................................................................47
8.3.4
Mixed venous blood gas (SvO2)...........................................................47
8.4
Safety.....................................................................................................................47
8.4.1
Physical examination ............................................................................47
8.4.2
Vital signs..............................................................................................48
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8.4.3
Height and weight .................................................................................48
8.4.4
Laboratory evaluations..........................................................................48
8.4.5
Electrocardiogram (ECG) .....................................................................49
8.4.6
Immunogenicity ....................................................................................49
8.4.7
Alcohol test and drug screen.................................................................50
8.4.8
AICD interrogation ...............................................................................50
8.4.9
Cardiac Holter and telemetry monitoring .............................................50
8.4.10
Fluid input and output...........................................................................50
8.5
Pharmacokinetics...................................................................................................50
8.5.1
PK blood collection...............................................................................51
8.5.2
PK assessments .....................................................................................51
8.5.3
PK urine collection (28-hour urine collection) .....................................51
8.6
Other assessments..................................................................................................52
9
Safety monitoring..............................................................................................................53
9.1
Adverse events.......................................................................................................53
9.2
Serious adverse event reporting.............................................................................54
9.2.1
Definition of SAE .................................................................................54
9.2.2
SAE reporting........................................................................................55
9.3
Liver safety monitoring .........................................................................................56
9.4
Renal safety monitoring.........................................................................................60
9.5
Pregnancy reporting...............................................................................................61
9.6
Prospective suicidality assessment ........................................................................61
9.7
Early phase safety monitoring ...............................................................................61
10 Data review and database management.............................................................................62
10.1
Site monitoring ......................................................................................................62
10.2
Data collection.......................................................................................................62
10.3
Database management and quality control............................................................62
10.4
Data Monitoring Committee..................................................................................63
10.5
Adjudication Committee........................................................................................63
11 Data analysis......................................................................................................................63
11.2
Subject demographics and other baseline characteristics......................................64
11.3
Treatments (study drug, rescue medication, other concomitant therapies, 
compliance)............................................................................................................64
11.4
Analysis of the primary variable(s) .......................................................................64
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11.4.1
Variable(s).............................................................................................64
11.4.2
Statistical model, hypothesis, and method of analysis..........................64
11.4.3
Handling of missing values/censoring/discontinuations.......................65
11.4.4
Supportive analyses...............................................................................65
11.5
Analysis of secondary and exploratory variables ..................................................65
11.5.2
Safety.....................................................................................................65
11.5.3
Pharmacokinetics ..................................................................................66
11.5.4
Pharmacokinetic / pharmacodynamic interactions................................66
11.5.5
Other assessments .................................................................................67
11.6
Sample size calculation..........................................................................................68
11.7
Power for analysis of key secondary variables......................................................68
12 Ethical considerations........................................................................................................68
12.1
Regulatory and ethical compliance........................................................................68
12.2
Responsibilities of the investigator and IRB/IEC..................................................69
12.3
Publication of study protocol and results...............................................................69
13 Protocol adherence ............................................................................................................69
13.1
Protocol Amendments ...........................................................................................69
14 References .........................................................................................................................71
List of tables
Table 8-1
Assessment Schedule ............................................................................41
Table 8-2
Permitted assessment windows.............................................................51
Table 9-1
Liver Event and Laboratory Trigger Definitions ..................................57
Table 9-2
Follow Up Requirements for Liver Events and Laboratory Triggers...58
Table 9-3
Specific Renal Alert Criteria and Actions.............................................60
List of figures
Figure 3-1
Study Design .........................................................................................27
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List of abbreviations
ACE
Angiotensin-converting enzyme
AICD
Automatic implantable cardioverter defibrillator
AE
adverse event
AEB
Additional Exploratory Biomarker
ALT
alanine aminotransferase
ARB
Angiotensin receptor blocker
AST
aspartate aminotransferase
BfArM
German Health Authority
BMI
Body Mass Index
BUN
blood urea nitrogen
CD-ROM
compact disc – read only memory
CFR
Code of Federal Regulation
CK
creatinine kinase
CRF
Case Report/Record Form (paper or electronic)
CV
coefficient of variation
ECG
Electrocardiogram
eCRF
Electronic Case Report Form
EDC
Electronic Data Capture
GCP
Good Clinical Practice
h
hour
i.v.
intravenous
IA
Interim Analysis
IC50
Half maximal inhibitory concentration
ICH
International Conference on Harmonization of Technical Requirements for 
Registration of Pharmaceuticals for Human Use
IEC
Independent Ethics Committee
IRB
Institutional Review Board
kg
Kilogram
LDH
lactate dehydrogenase
mg
milligram(s)
min
Minute
ml
milliliter(s)
PA Catheter
Pulmonary Artery Catheter
PD
pharmacodynamic(s)

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PK
pharmacokinetic(s)
RBC
red blood cell(s)
SAE
serious adverse event
SD
standard deviation
SOM
Site Operational Manual
SvO2
Mixed Venous Oxygen Saturation
TBL
total bilirubin
g
Microgram
ULN
upper limit of normal
WBC
white blood cell(s)

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Pharmacokinetic definitions and symbols
Ae0-t
Amount of drug (or defined metabolite) excreted into the urine from time 
zero to time 't' where t is a defined time point after administration [mass 
units or % of dose]
AUC0-t
The area under the plasma (or serum or blood) concentration-time curve 
from time zero to time 't' where t is a defined time point after 
administration [mass x time / volume]
AUCinf
The area under the plasma (or serum or blood) concentration-time curve 
from time zero to infinity [mass x time / volume]
AUClast
The area under the plasma (or serum or blood) concentration-time curve 
from time zero to the time of the last quantifiable concentration [mass x 
time / volume]
CL
The systemic (or total body) clearance from plasma (or serum or blood) 
following intravenous administration [volume / time]
CLr
The renal clearance from plasma (or serum or blood) [volume / time]
Cmax,ss
The observed maximum plasma (or serum or blood) concentration 
following drug administration at steady state [mass / volume]
T1/2
The terminal elimination half-life [time]
Tmax
The time to reach the maximum concentration after drug administration 
[time]
Vss
The volume of distribution at steady state following intravenous 
administration [volume]

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Protocol synopsis
Protocol number
CLR325X2202
Title
A randomized, subject and investigator-blinded, placebo-controlled study of 
CLR325 in chronic stable heart failure patients
Brief title
Safety, pharmacokinetics and efficacy study of CLR325 in stable heart failure 
patients.
Sponsor and Clinical 
Phase
Novartis
Phase IIa
Intervention type
Drug
Study type
Interventional 
Purpose and 
rationale
The purpose of this study is to determine the safety and tolerability of 
CLR325 in heart failure patients to determine if further clinical development of 
the drug in this indication is warranted.
Primary Objective(s)
To determine the safety and tolerability of an 18-hour i.v. infusion of CLR325 
in stable heart failure patients
Secondary 
Objectives
To determine the pharmacokinetics and immunogenicity of CLR325, and the 
active metabolite, CQJ295, during an 18-hour infusion of CLR325 in heart 
failure patients.
Study design
This is a non-confirmatory, randomized, subject and investigator-blind, 
placebo-controlled study of an 18-hour infusion of CLR325 in stable heart 
failure patients (who have a clinically indicated pulmonary artery catheter in 
place) to assess safety, tolerability, and pharmacokinetics in this patient 
population. This study has an adaptive dose design. A maximum of 40 
patients will be randomized. Initially, one cohort will be dosed: 6 patients with 
CLR325 and 2 with placebo. 
.
Population
Patients with stable heart failure >18 years of age
Inclusion criteria
Written informed consent must be obtained before any assessment is 
performed. 
Able to communicate well with the investigator, to understand and comply 
with the requirements of the study.
Male and female patients >18 years of age.
Patients must weigh between 50 kg and 140 kg to participate in the study.
Patients with a cardiac ejection fraction of ≤45% as assessed within the last 
6 months.
In the opinion of the investigator, heart failure patients who will not require a 
change in their dose of ACE, ARB, -blocker, mineralocorticoid receptor 
antagonist, or diuretic for 24 hours after randomization.
For PA catheter cohorts, patients who are planned to have a clinically 
indicated pulmonary artery catheter in place prior to randomization.
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At baseline, vital signs (systolic and diastolic blood pressure and pulse rate) 
will be assessed in the supine position after the subject has rested for at least 
five minutes.
Exclusion criteria
Presence of impaired renal function as indicated by clinically significant 
abnormal creatinine values (eGFR < 30 ml/min/1.73m2 calculated using the 
MDRD equation).
Patients with a history of chronic hepatitis of any non-cardiac etiology.
History of any active, clinically significant cardiac tachyarrhythmia, such as 
recurrent atrial fibrillation with rapid ventricular response within the last year.  
Note that patients with chronic atrial fibrillation with a pulse rate ≤ 100 bpm 
should not be excluded.
Patients who have received an intravenous infusion of a cardiac inotrope 
(e.g., dobutamine or milrinone) in the last 24 hours prior to randomization.
Patients with any significant change in their dose of their ACE, ARB, 
mineralocorticoid receptor antagonist, diuretic or β-blocker within the last 12
hours.
Patients with known significant valvular heart disease as indicated by the 
following:

Severe aortic stenosis (Aortic Valve Area < 1.0 cm2 or peak
gradient > 50 mmHg as determined by echocardiography)

Severe mitral stenosis
Patients with history of acute coronary syndrome within the last 60 days as 
determined by both clinical and enzymatic criteria. 
For PA catheter cohorts, patients with a pulmonary capillary wedge pressure 
of <10 mm Hg at baseline. For echocardiographic cohorts, patients with a 
lateral E/E’ ratio of <7 on their baseline echocardiogram. For patients in 
whom a lateral E/E’ ratio cannot be determined (e.g., patients in atrial 
fibrillation),
a central venous pressure of <5mm Hg on
baseline 
echocardiogram as determined by inferior vena cava criteria.
Investigational and 
reference therapy
CLR325 
Safety assessments
Physical exam, vital sign measurements, hematology and blood chemistry, 
cardiac panel, ECG, cardiac and telemetry monitoring will be obtained.
Data analysis
The occurrence of adverse events will be examined by treatment. Both the 
total number of adverse events, and the preferred term for the adverse event 
will be compared by treatment group.  Secondary analyses will be performed 
on pharmacokinetic parameters and presence of an immune response to 
CLR325 and anti-apelin antibodies.
Key words
Apelin, CLR325, chronic heart failure
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1
Introduction
Acute decompensated heart failure is commonly caused by deteriorating cardiac function that 
leads to unplanned, often urgent, medical intervention. There are ~500,000 hospitalizations 
annually for acute decompensated heart failure in the USA and the 30-day mortality following 
hospitalization is up to 11% (Jong et al 2002). Patients typically experience fatigue, 
breathlessness, fluid retention, and chest pain. The common treatment approach of 
vasodilators and diuretics is ineffective in a substantial proportion of heart failure patients 
with a reduced ejection fraction due to a predominant deficit in cardiac contractility. 
Intravenous inotropes, including dobutamine (β-agonist), and milrinone/amrinone (PDEIII 
inhibitors) are used to augment cardiac output in these patients and are associated with 
increased risk of arrhythmia and mortality (Felker and O'Connor 2001). In contrast, digoxin 
does not increase all-cause mortality, and reduces heart failure hospitalizations in patients 
with heart failure (Digitalis Investigation 1997), but it is a weak inotrope with a narrow 
therapeutic index. Therefore, new inotropic therapies that can effectively enhance cardiac 
function without increasing the risk of arrhythmias and/or mortality are urgently needed for 
patients with heart failure.
1.1
Background
CLR325 is a synthetic cyclic peptide and an apelin-13 analog being developed for the 
treatment of patients with acute decompensated heart failure. Apelin is the natural ligand for 
APJ, a G-protein-coupled receptor that shares 31% homology with the human angiotensin II 
receptor (for review, see O'Carroll et al 2013). Apelin is produced as an inactive 77-amino-
acid pre-pro-peptide that is cleaved into smaller, active fragments, such as apelin -36, -19, 
-17, -16, -13, and pyroglutamate-apelin-13 ((pyr1) apelin-13). Zhen et al 2013 recently
identified (pyr1) apelin-13 as the predominant apelin isoform in human plasma.
Apelin peptides increase contractility in isolated cardiomyocytes, ex vivo hearts, and in vivo
(Ashley et al 2005; Farkasfalvi et al 2007). Plasma apelin levels are significantly decreased in
heart failure patients (Chong et al 2006), and 6-hour infusion of (pyr1) apelin-13 into healthy
volunteers or heart failure patients induced a sustained increase in cardiac index
(Japp et al 2010; Barnes et al 2013). Also, low plasma apelin concentrations predicted
arrhythmia recurrence in patients with persistent atrial fibrillation (Falcone et al 2010),
suggesting that apelin peptides may be anti-arrhythmic. Taken together, these findings suggest
that apelin peptides may increase cardiac contractility in heart failure patients without causing
arrhythmias or increasing mortality.

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1.1.1
Relevant data summary
The most relevant data for the present study are summarized in the sections below. 
For detailed information, please refer to the CLR325 Investigators Brochure.
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1.2
Study purpose
The purpose of this study is to determine the safety and tolerability of CLR325 in stable heart 
failure patients to determine if further clinical development of the drug in a heart failure 
indication is warranted.
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2
Study objectives
2.1
Primary objective(s)
Primary objective(s)
Endpoints related to primary objective(s)

To determine the safety and
tolerability of an 18-hour i.v.
infusion of CLR325 in stable heart
failure patients.

Frequency of adverse events in CLR325 treated
patients as compared to patients treated with
placebo.

Frequency of clinically significant changes in
hematology or clinical chemistry laboratories or
changes in blood pressure or heart rate.
2.2
Secondary objective(s)
Secondary objective(s)
Endpoints related to secondary objective(s)

To determine the
pharmacokinetics of CLR325, and
the active metabolite, CQJ295,
during an 18-hour i.v. infusion of
CLR325 in heart failure patients.

Plasma and urine pharmacokinetic parameters of
CLR325 and CQJ295 (Cmax, Tmax, AUC0-18h,
AUClast, AUC0-28h, AUCinf, T1/2, CL
(CLR325 only), Vss (CLR325 only), CLr, and
Ae0-28 during the course of an 18-hour infusion
and post-infusion in heart failure patients.

To determine the immunogenicity
of an 18-hour i.v. infusion of
CLR325 in heart failure patients.

Treatment related titer of anti-CLR325 and anti-
apelin antibodies after infusion of CLR325 in
heart failure patients.
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3
Investigational plan
3.1
Study design
This is a non-confirmatory, randomized, subject and investigator-blind, placebo-controlled 
study of an 18-hour infusion of CLR325 in stable heart failure patients (who may have a 
clinically indicated pulmonary artery catheter in place) to assess safety, tolerability, and 
pharmacokinetics in this patient population.  Initially, one PA catheter cohort will be dosed: 
6 patients with CLR325 and 2 with placebo randomized using a block randomization scheme. 
The first cohort of patients will be those with chronic stable heart failure. For subsequent 
cohorts, patients with acute decompensation who have been stabilized following hospital 
admission may also be enrolled.  Following completion of the first cohort, subsequent cohorts 
may enroll concurrently as determined by the sponsor. 
The study will be comprised of a screening period of approximately 7 weeks (Day -45 to Day 
1), a baseline period (Day 1), a treatment period (Day 1-2) and a follow up period (Days 3-28).
Each treatment period will be comprised of a baseline pre-dosing interval (hour -1 to hour 0), 
an inpatient dosing interval (hour 1 to hour 18), and an inpatient post-dosing interval (hour 18 
to hour 28). In addition, patients will have a follow-up visit (Day 10) and an end-of-study visit 
on Day 28.  
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On Day -45 to 1, screening evaluations will be performed.  Study inclusion/exclusion criteria 
as well as medication use will be assessed during the screening and baseline periods. Patients 
who meet all of the inclusion and none of the exclusion criteria at screening will report to the 
study site on Day 1 of the baseline period, at a time specified by the investigator, and if they 
continue to meet all inclusion and none of the exclusion criteria, will remain in-house until the 
final 28 hour inpatient assessment in the treatment period.
On Day 1, pre-dose laboratory evaluations, cardiac hemodynamic monitoring, and 3-lead 
continuous telemetry monitoring will be performed. The sponsor will pre-specify if 
hemodynamics are to be monitored by a PA catheter, echocardiography, or both for each 
cohort.  For PA catheter cohorts, cardiac hemodynamics will be monitored continuously using 
a pulmonary artery catheter (that will have been placed for standard of care clinical 
indications by the subject's caregiver prior to randomization in the study) 
 Intracardiac pressures (right atrial, pulmonary artery) will 
be recorded every hour during the treatment period. Cardiac outputs will be obtained at hours 
-1, 0, 1, 3, 6, 8, 10, 12, 18, 20, 24, and 28 of the treatment period.  If not needed for standard
of care clinical indications, the pulmonary artery catheter may be removed after the final
cardiac output measurement at hour 28.  For echocardiographic cohorts, echocardiograms will
be obtained during the treatment period as specified in the SOM. Note that the sponsor's
decision regarding obtaining the echocardiogram will be applied uniformly across all patients
in the cohort.
Following the pre-dose procedures, eligible patients will be dosed intravenously. 
Post-dose evaluations will include routine laboratory evaluations, cardiac monitoring, 
continuous telemetry monitoring, 
. Patients may be released 
from the study site on Day 2, following completion of all 28-hour assessments, at the 
discretion of the investigator and if there are no safety concerns. The patients will be asked to 
return to the study site on Day 10 for a follow-up visit that will include a physical exam, 
routine laboratory evaluations, ECG evaluation
. An end-of-
study visit will be conducted on Day 28 and will include a physical exam, routine laboratory 
evaluations, ECG evaluation
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Figure 3-1
Study Design

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3.4
Rationale for choice of comparator
A normal saline intravenous infusion will be used as a comparator to CLR325 in this study. 
Normal saline was chosen as this is visually indistinguishable from the CLR325 infusion and 
is the excipient for the CLR325 infusion. Also, the total volume of normal saline or CLR325 
infusion given in this study over 18 hours 
 will have minimal effects on 
cardiac hemodynamics of study subjects.
3.6
Risks and benefits
This study will be conducted in patients with stable heart failure to assess the status of their 
disease. 
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Based on a human trial of (pyr1) apelin-13 (Barnes et al 2013), it is also possible that CLR325 
could lead to an increase in blood pressure in treated subjects which could lead to symptoms 
of chest pain, shortness of breath, or headache in affected subjects. In addition, it is possible 
that by increasing cardiac contractility, cardiac filling pressures may drop, leading to a 
paradoxical drop in blood pressure. This might result in subjects developing symptoms of 
dizziness, lightheadedness, chest pain, or shortness of breath. Finally, it is possible that 
CLR325 could induce sustained cardiac arrhythmias such as ventricular tachycardia or 
supraventricular tachycardia leading to symptoms of palpitations, dizziness, lightheadedness, 
shortness of breath, chest pain, or trigger a subject's AICD to discharge. 
 The risk to subjects in this trial will be minimized by 
adherence to the inclusion/exclusion criteria, close clinical monitoring, in-patient status, and 
study “stopping rules". In addition to the potential risks outlined below, there are unknown 
risks to CLR325, which may be serious and unforeseen.
The 18 hours i.v. infusion requiring an indwelling catheter could potentially lead to 
discomfort, development of hematoma or in rare cases of phlebitis.
3.6.1
Potential risks associated with blood collection
Blood samples will be collected frequently during the study either via venipuncture or i.v. 
cannula. The total volume to be collected over the course of the study is approximately 
251 mL. Risks associated with blood collection include pain, swelling and/or bruising at the 
insertion site of the needle. Although rare, localized clot formation, infections and nerve 
damage may occur. Lightheadedness and/or fainting may also occur during or shortly after the 
blood draw.
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3.6.2
Potential risks associated with immunogenicity
The presence of anti-CLR325 antibodies and anti-apelin antibodies will be determined in all 
study subjects. The risk of developing anti-CLR325 and anti-apelin antibodies in humans is 
unknown; 
 Since CLR325 
is an apelin analog, it is possible that antibodies directed against CLR325 could cross-react 
with endogenous apelin. The development of neutralizing antibodies towards endogenous 
apelin might be associated with adverse events. Mice deficient in apelin have an increased 
propensity to develop heart failure following aortic banding or aging (Kuba et al 2007); 
however, it is unknown what the consequences of neutralizing endogenous apelin are in 
normal mice or humans. Subjects that develop anti-apelin antibodies will be followed with 
repeat immunogenicity assessments until their levels of anti-apelin antibodies are undetectable. 
The need for medical intervention will be dependent on the study subject’s condition and the 
standard of medical care. The timing of follow up laboratory assessments, their interpretation 
and need for medical intervention will be made jointly by the Investigator and Sponsor.
3.6.3
Potential risks associated with infusion-related reactions
 Hypersensitivity reactions can manifest as fever, chills, urticaria, 
dyspnea, headaches, myalgia, and/or hypotension. If a severe hypersensitivity reaction occurs, 
CLR325 should be discontinued and appropriate therapy should be initiated (e.g., 
antihistamines, corticosteroids, airway support, etc.).
 infusion sites should 
be closely monitored during the study for signs of an allergic response, inflammation or 
thrombosis. Infusions should be discontinued in any subject with such signs and appropriate 
therapy should be initiated as needed (e.g., antihistamines, corticosteroids, etc.).
3.6.4
Potential risks associated with systemic inflammation
Subjects showing signs or symptoms of systemic inflammation 
(elevated white blood cell count above 2.5x the ULN, fever) should be discontinued from 
CLR325 infusion and supportive care initiated as clinically indicated.
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3.6.5
Potential risks associated with a PA catheter
Risks associated with continued invasive hemodynamic monitoring by a PA catheter may 
include complications such as bleeding and infection. The risk of infections will be limited by 
sterile procedures. The rate of bleeding complications from the PA catheter has been reported 
at 1.9% to 4%, and PA catheter infections with an incidence of 1.9%. Through stimulation of 
the myocardium, atrial and ventricular arrhythmias can occur which are generally without 
hemodynamic relevance and self-limiting, occurring with an incidence of 0.5-3%. Pulmonary 
infarction has also been reported at an incidence of approximately 1% (Binanay et al 2005, 
Harvey et al 2005).
4
Population
The study population will be composed of adult male and female patients with stable heart 
failure with reduced ejection fraction. These patients will have been diagnosed with heart 
failure with reduced ejection fraction at least 6 months prior to study enrollment.
Studies to assess reproductive toxicology have not yet been performed. Women who are of 
child bearing potential, currently pregnant, or have been pregnant in the last 6 months, are 
excluded from this study. This exclusion is in place to prevent women with a newly diagnosed 
peri-partum cardiomyopathy from being included in this study.
4.1
Inclusion criteria
1. Written informed consent must be obtained before any assessment is performed.
2. Able to communicate well with the investigator, to understand and comply with the
requirements of the study.
3. Male and female patients >18 years of age.
4. Patients must weigh between 50 kg and 140 kg to participate in the study.
5. Patients with a cardiac ejection fraction of ≤45% assessed within the last 6 months.
6. For PA catheter cohorts, patients who are planned to have a clinically indicated pulmonary
artery catheter in place prior to randomization.
7. In the opinion of the investigator, heart failure patients who will not require a change in
their dose of ACE, ARB, -blocker, mineralocorticoid receptor antagonist, or diuretic for
24 hours after randomization.
8. At baseline, vital signs (systolic and diastolic blood pressure and pulse rate) will be
assessed in the supine position with the head of the bed at 30o after the subject has rested
for at least five minutes. Supine vital signs should be within the following ranges:

oral body temperature between 35.0-37.5 °C

systolic blood pressure, 90-140 mm Hg

diastolic blood pressure, 50-90 mm Hg

pulse rate, 50 - 100 bpm
If blood pressure or heart-rate is out-of-range at screening or baseline, the Investigator may 
obtain two additional readings, so that a total of up to three consecutive assessments are made, 
with the subject resting quietly in supine position for approximately 5 minutes preceding each 

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repeat assessment. At least the last reading must meet the inclusion criteria in order for the 
subject to qualify.
4.2
Exclusion criteria
1. Use of other investigational drugs at the time of enrollment, or within 5 half-lives of
enrollment, or until the expected PD effect has returned to baseline, whichever is longer;
or longer if required by local regulations.
2. History of hypersensitivity to the study drug or to drugs of similar chemical classes.
3. As per the investigator's judgement, a history of tobacco, drug or alcohol abuse that will
compromise the patient's ability to participate in this study.
4. Currently pregnant, pregnant within the last 6 months, or nursing (lactating) women.
5. Women of child-bearing potential, defined as all women physiologically capable of
becoming pregnant. Women are considered post-menopausal and not of child bearing
potential if they have had 12 months of natural (spontaneous) amenorrhea with an
appropriate clinical profile (e.g. age appropriate, history of vasomotor symptoms) or have
had surgical bilateral oophorectomy (with or without hysterectomy) or tubal ligation at
least six weeks ago. In the case of oophorectomy alone, only when the reproductive status
of the woman has been confirmed by follow up hormone level assessment is she
considered not of child bearing potential.
6. Sexually active males must use a condom during intercourse while taking drug and for
10 hours (= 5 times the terminal half-life of investigational medication) after stopping
CLR325 and should not father a child in this period. A condom is required to be used also
by vasectomized men in order to prevent delivery of the drug via seminal fluid.
7. Chronic infection with Hepatitis B (HBV) or Hepatitis C (HCV). A positive Hepatitis B
surface antigen (HBsAg) test excludes a patient. Patients with a positive Hepatitis C
antibody test should have HCV RNA levels measured. Patients with positive (detectable)
HCV RNA should be excluded.
8. Patients with a history of chronic hepatitis of any non-cardiac etiology.
9. Patients with values of AST or ALT >100 U/L measured within the last 3 months before
randomization.
10. Presence of impaired renal function as indicated by clinically significant abnormal
creatinine values (eGFR < 30 ml/min/1.73m2 calculated using the MDRD equation).
11. Known family history or known presence of long QT syndrome.
12. History of any active, clinically significant cardiac tachyarrhythmia (such as recurrent
atrial fibrillation with rapid ventricular response) within the last year. Note that patients
with chronic atrial fibrillation with a pulse rate ≤ 100 bpm should not be excluded.
Anticoagulation for patients with atrial fibrillation should be managed per usual clinical
practice for patients undergoing right heart catheterization.
13. Patients with known significant valvular heart diseaseas indicated by the following:

severe aortic stenosis (Aortic Valve Area < 1.0 cm2 or peak gradient > 50 mm Hg as
determined by echocardiography)

severe mitral stenosis

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14. Patients with history of acute coronary syndrome within the last 60 days as determined by
both clinical and enzymatic criteria.
15. For echocardiography-based cohorts only, patients admitted to an inpatient setting for
acute decompensated heart failure within the last 30 days.
16. Patients who have received an intravenous infusion of a cardiac inotrope (e.g., dobutamine
or milrinone) in the last 24 hours prior to randomization.
17. For PA catheter cohorts, patients with a pulmonary capillary wedge pressure of <10 mm
Hg at baseline. For echocardiographic cohorts, patients with a lateral E/E’ ratio of <7 on
their baseline echocardiogram.  For patients in whom a lateral E/E’ ratio cannot be
determined (e.g., patients in atrial fibrillation), a central venous pressure of <5mm Hg on
baseline echocardiogram as determined by inferior vena cava criteria.
18. Patients with any significant change in their dose of their ACE, ARB, mineralocorticoid
receptor antagonist, diuretic, or β-blocker within the last 12 hours.  Patients with minor
changes in their heart failure regimen may be eligible if deemed clinically stable by both
the investigator and sponsor.
19. Any surgical or medical condition which in the opinion of the investigator may place the
subject at higher risk from his/her participation in the study.
No additional exclusions may be applied by the investigator, in order to ensure that the study 
population will be representative of all eligible patients.
5
Restrictions for Study Subjects
During recruitment, screening/informed consent review, and baseline visit, the subjects must 
be informed and reminded of the following restrictions:
5.1
Contraception requirements
Please refer to exclusion criteria (Section 4) for details of contraception requirements for the 
study.
5.2
Prohibited treatment
Any cardiac intravenous inotrope such as dobutamine or milrinone is prohibited. Digitalis is 
allowed if the patient has been on a stable dose for at least 2 weeks prior to entry into the 
study.
5.3
Dietary restrictions and smoking
Patients will be domiciled in a hospital setting during the treatment period, and therefore will 
not be allowed to drink alcohol or smoke during this time.
5.4
General restrictions
Patients will have limited mobility due to the PA catheter during the treatment period. 

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6
Treatment
6.1
Study treatment
Details on the storage and management of study medication, randomization and instructions 
for prescribing and taking study treatment are outlined in Section 3 of the Site Operations 
Manual.
6.1.1
Investigational treatment
The investigational treatment, CLR325 
 will be prepared by Novartis and supplied to an unblinded pharmacist at the site as open 
label bulk medication. The unblinded pharmacist will prepare the appropriate dose depending 
on the cohort (detailed instructions will be provided in the pharmacy manual). Normal saline 
will be used as a placebo (will be arranged by sites locally).
Study drugs must be received at the study site by a designated person, handled and stored 
safely and properly, and kept in a secure location to which only the Investigator and 
designated staff have access. 
Upon receipt, the study drugs should be stored according to the instructions specified on the 
drug labels. Storage conditions must be adequately monitored and appropriate temperature 
logs maintained as source data. Appropriate documentation of the subject specific dispensing 
process must be maintained. 
Medication labels will be in the local language, will comply with the legal requirements of 
each country, and will include storage conditions for the drug but no information about the 
patient
6.2
Treatment arms
Patients will be assigned to one of the following 2 treatment arms in fixed randomization ratio 
(CLR325:Placebo):

Single dose of CLR 325 (i.v.)

Single dose of Placebo (i.v.)
6.3
Permitted dose adjustments and interruptions of study treatment
Should there be any technical problems with the infusion line (i.e. infiltration, infusion pump 
malfunction) the infusion must be restarted within 30 minutes or the patient will be considered 
discontinued from treatment and the infusion shall not be restarted.
Dosage may be discontinued if required to address any safety concerns and should not be 
restarted. Dose adjustments of study treatment will not be permitted.
6.4
Treatment assignment
Randomization numbers will be assigned in ascending, sequential order to eligible subjects 
(see Site Operation Manual for details). The randomization number becomes the definitive 
subject number as soon as a subject receives the first dose of the respective study treatment. 
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The investigator will enter the randomization number in the eCRF system. The randomization 
numbers will be generated using the following procedure to ensure that treatment assignment 
is unbiased and concealed from subjects and investigator staff. A randomization list will be 
produced by or under the responsibility of Novartis Drug Supply Management using a 
validated system that automates the random assignment of treatment arms to randomization 
numbers in the specified ratio. The randomization scheme for subjects will be reviewed and 
approved by a member of the Novartis IIS Randomization Group.
6.5
Treatment blinding
The sponsor will be unblinded to treatment during this study.  Patients, investigator staff, and 
persons performing the assessments will remain blind to the identity of the treatment from the 
time of randomization until database lock, using the following methods:
1. Randomization data are kept strictly confidential until the time of unblinding, and will not 
be accessible by patients, site staff, and study investigators with the exception of the 
unblinded site pharmacy staff.
2. The identity of the treatments will be concealed by the use of study drugs that are all 
identical in packaging, labeling, and schedule of administration.
See the Site Operation Manual for further details on blinding.
Unblinding will only occur in the case of subject emergencies (Section 6.6) and at the time of 
the interim analysis (see Section 3.5) and at the conclusion of the study. An assessment will 
be done by the appropriate site personnel and the sponsor for any subject whose treatment 
code has been broken inadvertently or for any non-emergency reason to assess whether or not 
study drug should be discontinued.
6.6
Emergency breaking of assigned treatment code
Emergency unblinding should only be undertaken when it is essential to treat the subject 
safely and efficaciously. Most often, study treatment discontinuation and knowledge of the 
possible treatment assignments are sufficient to treat a study subject who presents with an 
emergency condition. A complete set of emergency code break cards will be provided to the 
investigator site(s) and a complete set will be available at Novartis. All code break cards must 
be retained until the end of the study and returned to Novartis. They must be stored in a secure 
place but be accessible in case of emergency. The investigator will receive a blinded code 
break card for each subject, with the details of drug treatment covered by a removable, 
scratch-off cover. In an emergency, the scratch-off cover can be removed to determine the 
treatment. The scratch-off covers are not to be removed for any reason other than an 
emergency. When the investigator removes the scratch-off cover he/she must note the date, 
time, and reason for removing it and retain this information with the case report form 
documentation. The unblinded treatment code should not be recorded on the CRF. 
The investigator must also immediately inform the Novartis local monitor that the code has 
been broken.
It is the investigator’s responsibility to ensure that there is a procedure in place to allow access 
to the code break cards in case of emergency. If appropriate, the investigator will inform the 
subject how to contact his/her backup in cases of emergency when he/she is unavailable. 

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An assessment will be done by the appropriate site personnel and the sponsor after an 
emergency unblinding to assess whether or not study drug should be discontinued for a given 
patient and, if applicable, whether the patient can continue. Patients who undergo emergency 
unblinding and are discontinued cannot be re-enrolled in the study.
6.7
Treatment exposure and compliance
Patients will receive all study medication at the Investigator site. Study medication will be 
administered by site personnel, compliance will be ensured by appropriate training of site 
personnel. The date and time of administration of study drug will be recorded in the dosage 
administration record section of the eCRF.
Pharmacokinetic parameters (i.e., measures of treatment exposure) will be determined in all 
subjects treated with CLR325.
6.8
Recommended treatment of adverse events
At present there is insufficient information to provide specific recommendations regarding 
treatment of adverse events. Medication used to treat AEs must be recorded on the 
Concomitant medications/Significant non-drug therapies section of the source documentation.
Medication used to treat AEs must be recorded on the Concomitant medications/Significant 
non-drug therapies CRF.
6.9
Rescue medication
Rescue medications are not applicable given that all patients in this study will have stable 
disease.
6.10
Concomitant treatment
All prescription medications, over-the-counter drugs and significant non-drug therapies 
(including physical therapy and blood transfusions) administered or taken within the 
timeframe defined in the entry criteria prior to the start of the study and during the study, must 
be recorded on the Concomitant medications/ Significant non-drug therapies section of the 
(e)CRF. Medication entries should be specific to trade name, the single dose and unit, the
frequency and route of administration, the start and discontinuation date and the reason for
therapy.
While it is preferred that changes in prescription medications should not be made during the 
treatment period, changes in patient's baseline medications are allowed if deemed necessary 
by the investigator.
7
Discontinuation and study completion
7.1
Discontinuation of study treatment
Patients may voluntarily discontinue study treatment for any reason at any time.

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The investigator must discontinue study treatment for a given patient if, on balance, he/she 
believes that continuation would be detrimental to the patient's well-being.
Study treatment must be discontinued under any of the following circumstances: 

Patient withdraws consent  

Any protocol deviation that results in a significant risk to the subject's safety 

Emergence of the following adverse events:  

Acute myocardial infarction

Worsening myocardial ischemia

Sustained atrial or ventricular tachycardia 

AICD discharge or anti-tachycardia pacing by the AICD in a patient with an 
AICD in place

An increase in non-sustained ventricular tachycardia or ventricular ectopy deemed 
clinically concerning by the investigator

Severe allergic reaction (e.g., angioedema)

Occurrence of persistent elevation of systolic blood pressure to >180 mmHg or 
diastolic blood pressure >100 mm Hg

Occurrence of symptomatic hypotension requiring persistent medical intervention (i.e.
fluid replacement or inotropic therapy).  Note that change of patient position does not 
qualify as an intervention if the need for this change in position is not persistent

A drop in cardiac index of > 30% as compared to the average of all cardiac index 
measurements obtained prior to the start of infusion.  All cardiac index valves showing 
a 30% drop from baseline should be repeated and study drug terminated only if values 
are confirmed.

Any clinically significant cardiac arrhythmia resulting in hemodynamic instability or 
requiring medical intervention to terminate

Any of the following laboratory abnormalities: 

Elevation in white blood cell count to greater than 2.5x above the ULN

Elevated AST or ALT > 8x above the ULN

Elevated AST or ALT > 3x above the ULN and TBL > 2x the ULN but without an 
increase in ALP to >2x the ULN

Elevated AST or ALT > 3x above the ULN and symptoms of malaise, fatigue, 
abdominal pain, nausea, vomiting, or rash with eosinophilia.
The appropriate personnel from the site and Novartis will assess whether study treatment 
should be discontinued for any patient whose treatment code has been broken inadvertently 
for any reason.
Patients who discontinue study treatment or who decide they do not wish to participate in the 
study further should NOT be considered withdrawn from the study UNLESS they withdraw 
their consent (see protocol Section 7.3). They should return to the clinic as soon as possible 
for the end of study visit assessments indicated in the Assessment Schedule. If they fail to 
return for these assessments for unknown reasons, every effort (e.g. telephone, e-mail, letter) 
should be made to contact them as specified in protocol Section 7.2.1.

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Subjects who are withdrawn from the study for reasons other than safety, the decision to 
replace them by an equal number of newly enrolled subjects will be taken by the Sponsor. 
7.2
Study completion and post-study treatment
Each patient will be required to complete the study in its entirety and thereafter no further 
study treatment will be made available to them. Study completion is defined as when the last 
patient completes their End of Study visit, and any repeat assessments associated with this 
visit have been documented and followed-up appropriately by the Investigator, or in the event 
of an early study termination decision, the date of that decision.
7.2.1
Lost to follow-up
For patients whose status is unclear because they fail to appear for study visits without stating 
an intention to discontinue or withdraw, the investigator should show "due diligence" by 
documenting in the source documents steps taken to contact the subject, e.g. dates of 
telephone calls, registered letters, etc. A subject should not be formally considered lost to 
follow-up until his/her scheduled end of study visit would have occurred.
7.3
Withdrawal of consent
Subjects may voluntarily withdraw consent to participate in the study for any reason at any 
time. Withdrawal of consent occurs only when a subject:

Does not want to participate in the study anymore, and

Does not allow further collection of personal data
In this situation, the investigator should make a reasonable effort (e.g. telephone, e-mail, letter) 
to understand the primary reason for the subject’s decision to withdraw his/her consent and 
record this information. 
Study treatment must be discontinued and no further assessments conducted, and the data that 
would have been collected at subsequent visits will be considered missing. 
Further attempts to contact the subject are not allowed unless safety findings require 
communicating or follow-up.
All efforts should be made to complete the assessments prior to study withdrawal. A final 
evaluation at the time of the subject’s study withdrawal should be made as detailed in the 
assessment table. 
Novartis will continue to keep and use collected study information (including any data 
resulting from the analysis of a subject’s samples until their time of withdrawal) according to 
applicable law.
For US sites:  All biological samples not yet analyzed at the time of withdrawal may still be 
used for further testing/analysis in accordance with the terms of this protocol and of the 
informed consent form.

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For EU and RoW sites: All biological samples not yet analyzed at the time of withdrawal will 
no longer be used, unless permitted by applicable law. They will be stored according to 
applicable legal requirements.
7.4
Study Stopping rules
The study will be paused and no further dosing will be conducted pending a full, unblinded 
safety review if any of the following criteria are met:

One or more SAE’s are reported

If 2 or more patients experience an AE that is similar and of severe grade

If 2 or more patients have their infusion discontinued for safety or tolerability reasons

A CLR325-treated patient develops anti-apelin antibodies

The principal investigator and the sponsor consider that the number and/or severity of
adverse events justify discontinuation of the study

The sponsor unilaterally requests it
7.5
Early study termination
The study can be terminated at any time for any reason by Novartis. Should this be necessary, 
patients should be seen as soon as possible and treated as a prematurely withdrawn patient. 
The investigator may be informed of additional procedures to be followed in order to ensure 
that adequate consideration is given to the protection of the patient's interests.
The investigator will be responsible for informing IRBs/IECs of the early termination of the 
trial.

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8
Procedures and assessments
Table 8-1
Assessment Schedule
Study Phase
Screening
Baseline
Treatment
Follow-up
EOS
Visit Numbers1
V1
V2
V3
V4
V777
Study Day(s)
(windows)
-45 to 1
1
1 to 2
10
(-3 +3)
28
(-5 +5)
Time (post-dose)
-
-
-1h2
0h
1h
3h
6h
8h
10h
12h
18h
20h
24h
28h
-
-
Informed consent
X
X
Inclusion / Exclusion criteria
X
X
Medical history/current 
medical conditions
X
X
Concomitant therapies
X
X
Demography
X
Alcohol Test and Drug 
Screen 
X
Hepatitis3
X
Pregnancy test
X
X4
Body weight
X
X
X
X
X
Fluid Input and Output
X
Vital Signs
X
X
X5
X
X
Physical examination
X
X
X6
X
X
Hematology
X
X
X
X
X
X
X
X
Blood chemistry
X
X
X
X
X
X
X
X
Coagulation
X
X
X
X
X
X
Urinalysis
X
X
X
X
X
28-hr urine collection
X7
CCI

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Study Phase
Screening
Baseline
Treatment
Follow-up
EOS
Visit Numbers1
V1
V2
V3
V4
V777
Study Day(s)
(windows)
-45 to 1
1
1 to 2
10
(-3 +3)
28
(-5 +5)
Time (post-dose)
-
-
-1h2
0h
1h
3h
6h
8h
10h
12h
18h
20h
24h
28h
-
-
ECG evaluation
X
X
X8
X9
X9
X9
X9
X9
X
X
X
PK blood collection10
See table below
See table below
See table below
See table below
See table below
Immunogenicity
X
X
X
Cardiac Hemodynamic 
monitoring11
X
X
PA catheter derived Cardiac 
Output12
X
Mixed venous blood gas12
X
Telemetry cardiac 
monitoring13
X
Echocardiogram14
X
X
AICD Interrogation15
X
X
Study drug administration
X
Subjects domiciled
X
Study completion information
X
AEs and SAEs
X16
1 Visit structure given for internal programming purpose only
2 (-) 1 hour assessments need to be at LEAST 1 hour prior to dose administration.
CCI
CCI

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Study Phase
Screening
Baseline
Treatment
Follow-up
EOS
Visit Numbers1
V1
V2
V3
V4
V777
Study Day(s)
(windows)
-45 to 1
1
1 to 2
10
(-3 +3)
28
(-5 +5)
Time (post-dose)
-
-
-1h2
0h
1h
3h
6h
8h
10h
12h
18h
20h
24h
28h
-
-
3 If obtained within the past 2 months, sites may confirm with proper documentation that Hepatitis serologie’s have been evaluated.
4 Urine dipstick
5 Vital signs will be measured manually by staff.  At hour 0 a complete set of vital signs will be measured.  Blood pressure and pulse rate will be measured during 
treatment period timepoint: 15 minutes, 30 minutes and 45 minutes post dose.  A complete set of vital signs will be measured hourly thereafter, from hour 1 to hour 28.  
Complete vital signs consist of Blood Pressure, Pulse Rate, Body Temperature, Respiratory Rate and Oxygen Saturation.  For the hourly vital sign assessments there is a 
window of +/- 10 minutes.
6For the physical exam performed during treatment period (at 24h), a +/- 30 min window is allowed.
7 Patient should void prior to the start of the infusion. Urine collection for 28 hours will begin at the start of infusion.
8 ECG may be evaluated up to 45 minutes prior to t=0.
9 Assessment windows for ECGs during Treatment may be +/- 30 minutes.
10 Assessment window for PK blood collection during Treatment period at 0 hour may be within 60 min prior to start of infusion.   A +/- 5 min window is allowed post start 
of infusion up to 28 hours post infusion. See Table 6-1 of SOM.
11 Continuous Cardiac Hemodynamics will be monitored using a pulmonary artery catheter, every 15 minutes from hour -1 to hour 1 in the treatment period, and hourly for 
the remainder of the treatment period. See SOM for more details.
13 3 lead continuous telemetry to begin pre-dose and will be discontinued up to 28 hours post infusion.
14 For echocardiography cohorts only.  Sites will be notified if echo will be performed (for the full cohort).
15 If patient has AICD in place.
16 As required
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Details for highly repetitive assessments
Study 
Phase
Visit
Day
Time (post-
dose)
PK blood 
collection
Screening
V1
-45 to 1
-
X
Baseline
V2
1
-
Treatment
V3
1 to 2
-1h1
0h
X
X
X
X
X
0.5h
X
1h
3h
X
5h
X
6h
8h
X
10h
X
12h
X
18h
X
X
X
X
X
20h
X
24h
X
28h
X
X
X
X
X
Follow-up
V4
10
-3 +3
-
X
X
X
X
X
EOS
V777
28
-5 +5
-
X
X
X
X
X
1 (-) 1 hour assessments need to be at LEAST 1 hour prior to dose administration.
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8.1
Informed consent procedures
Eligible patients may only be included in the study after providing written (witnessed, where 
required by law or regulation), IRB/IEC-approved informed consent.
If incapable of doing so, in cases where the patient's representative gives consent, the patient 
should be informed about the study to the extent possible given his/her understanding. If the 
patient is capable of doing so, he/she should indicate assent by personally signing and dating 
the written informed consent document or a separate assent form.
Informed consent must be obtained before conducting any study-specific procedures (i.e. all 
of the procedures described in the protocol). The process of obtaining informed consent 
should be documented in the patient source documents.
The date of signing of informed consent (and withdrawal, if later withdrawn) should be 
documented in the CRF.
Novartis will provide to investigators a proposed informed consent form that complies with 
the ICH GCP guideline and regulatory requirements and is considered appropriate for this 
study. Any changes to the proposed consent form suggested by the investigator must be 
agreed to by Novartis before submission to the IRB/IEC.
Pregnancy outcomes must be collected for the female partners of any males who took study 
treatment in this study. Consent to report information regarding these pregnancy outcomes 
should be obtained from the mother. 
8.2
Subject demographics/other baseline characteristics
Demographic and baseline characteristic data will be collected on all patients.
Relevant medical history/current medical conditions data includes data until signature of 
informed consent. Where possible, diagnoses and not symptoms will be recorded.
Investigators have the discretion to record abnormal test findings on the medical history CRF 
whenever in their judgment, the test abnormality occurred prior to the informed consent 
signature.
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8.3.2
Invasive hemodynamic monitoring
For PA catheter cohorts, the clinically indicated pulmonary artery catheter placed prior to 
entry into the study will remain in place until the end of the treatment period.  The following 
parameters are measured:

Right atrial pressure (RAP) in mmHg

Systolic and diastolic right ventricular pressure (RVP) in mmHg – only required in
patients with a PA catheter with RV ports capable of measuring RV pressures.

Systolic and diastolic pulmonary arterial pressure (PAP) in mmHg

Pulmonary capillary wedge pressure (PCWP) in mmHg

Cardiac output (CO) in L/min

Brachial systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate -
measured with each set of hemodynamic measurements
In addition pulse oximetry will be used to measure

Peripheral arterial oxygen saturation SaO2 in %
Derived hemodynamic parameters are:

Systemic vascular resistance (SVR) in dynes•sec/cm5

Pulmonary vascular resistance (PVR) in dynes•sec/cm5

Mean PAP in mmHg

Stroke volume (SV) in mL

Cardiac index (CI) in L/min/m2
The hemodynamic measurements are repeated as indicated in the Site Operations Manual. 
In the event of any clinically significant change in hemodynamic measurements, additional 
hemodynamic measurements will be obtained at greater frequency as outlined in the Site 
Operations Manual. The hemodynamic measurements are done immediately before blood 
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collection at each time point.  All hemodynamic parameters will be entered in the eCRF. 
Details of the hemodynamic measurements will be described in the Site Operations Manual.
8.3.3
Echocardiogram
A limited echocardiogram will be performed for an entire dosing cohort for those cohorts 
designated by the sponsor as echocardiography cohorts. If the site enrolls a subject in the 
echocardiographic cohort, the baseline scan will be evaluated locally to confirm patients with 
a lateral E/E’ ratio of <7 will be excluded. 
The complete technical details of the equipment and machine settings will be captured in a 
separate echocardiographic manual prepared by an imaging CRO who will perform all 
analysis for determining cardiac output, ventricular volumes, and left ventricular ejection 
fraction. In brief, a Doppler flow evaluation to determine the blood flow velocity across the 
aortic valve will be acquired over multiple cardiac cycles which, along with heart rate, will be 
used to determine cardiac output. Additional measurements of ventricular volumes (systole 
and diastole) and left ventricular ejection fraction will also be captured.   The image data will 
be collected from sites by an imaging CRO for central reading and reporting of the 
quantitative image analysis.   A detailed Echocardiogram Manual will be provided to all sites 
participating in this imaging assessment which includes the acquisition and image transfer 
details.
8.3.4
Mixed venous blood gas (SvO2)
For PA catheter cohorts, a blood sample will be withdrawn from the PA catheter for a 
measurement of oxygen saturation (SvO2) at the times indicated in the Assessment Schedule.
8.4
Safety
Safety assessments are specified below; methods for assessment and recording are specified in 
the Site Operations Manual, with the Assessment Schedule detailing when each assessment is 
to be performed.
8.4.1
Physical examination
A complete physical examination will include the examination of general appearance, skin, 
neck (including thyroid), eyes, ears, nose, throat, lungs, heart, abdomen, back, lymph nodes, 
extremities, vascular and neurological. If indicated based on medical history and/or symptoms, 
rectal, external genitalia, breast, and/or pelvic exams may be performed.
Information for all physical examinations should be included in the source documents and 
will not be transferred to the sponsor as part of the study analysis. Significant findings that are 
present prior to informed consent are included in the Relevant Medical History section of the 
source documents. Significant findings observed after informed consent signature which meet 
the definition of an Adverse Event must be appropriately recorded on the Adverse Event 
eCRF section.

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8.4.2
Vital signs
Vital signs include blood pressure (BP), pulse rate, respiratory rate, body temperature and 
peripheral oxygen saturation (SaO2). After the subject has been supine for approximately 
5 minutes systolic and diastolic BP will be measured once using an automated validated 
device, with an appropriately sized cuff. In case the cuff sizes available are not large enough 
for the subject’s arm circumference, a sphygmomanometer with an appropriately sized cuff 
may be used.
8.4.3
Height and weight
Height in centimeters (cm) (without shoes) will be measured.
Body weight (to the nearest 0.1 kilogram [kg] in indoor clothing, but without shoes) will be 
measured.
Body mass index (BMI) will be calculated using the following formula:

BMI = Body weight (kg) / [Height (m)]2
8.4.4
Laboratory evaluations
Clinically relevant deviations of laboratory test results occurring during or at completion of 
the study must be reported and discussed with Novartis personnel. The results should be 
evaluated for criteria defining an adverse event and reported as such if the criteria are met. 
Repeated evaluations are mandatory until normalization of the result(s) or until the change is 
no longer clinically relevant. In case of doubt, Novartis personnel should again be contacted.
Hematology
Hemoglobin, hematocrit, erythrocyte sedimentation rate, red blood cell count, white blood 
cell count with differential and platelet count will be measured.
Clinical chemistry
Sodium, potassium, 
 uric acid, chloride, albumin, calcium, magnesium, phosphate, 
alkaline phosphatase, amylase, bicarbonate, indirect bilirubin, direct bilirubin, total bilirubin, 
blood urea nitrogen, LDH, GGT, AST, ALT, 
, glucose, total cholesterol, 
triglycerides, 
 C-reactive protein, 
 t
If the total bilirubin concentration is increased above 1.5 times the upper limit of normal, 
direct and indirect reacting bilirubin should be differentiated.
Coagulation
PT (reported as INR), aPTT.
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Urinalysis
Urine test by dipstick e.g. Combur9: leucocytes, nitrite, pH, protein, glucose, ketones, 
urobilinogen, bilirubin, blood/ hemoglobin, specific gravity.
If the dipstick result is positive for protein, nitrite, leucocytes and/or blood, the sample will be 
sent for microscopic analysis of WBC, RBC and casts.
Hepatitis screen
All subjects will be tested for Hepatitis B and Hepatitis C seropositivity at the screening visit. 
Hepatitis B will be evaluated using the Hepatitis B surface antigen (HBsAg). Screening for
Hepatitis C will be based on HCV antibodies. Patients with a positive Hepatitis C antibody 
test should have HCV RNA levels measured.
Results will be available as source data and will not be recorded within the clinical database.
8.4.5
Electrocardiogram (ECG)
ECG evaluations will be obtained at specific time points specified in the Assessment Schedules.
A standard 12-lead ECG will be performed with the subject in a supine position. 
Interpretation of the tracing must be made by a qualified physician and documented on the 
ECG and in the ECG section of the source document. Each ECG tracing should be labeled 
with the

study number

patient initials

patient number

date
and kept in the source documents at the study site. Clinically significant abnormalities should 
be recorded on the relevant medical history eCRF page prior to informed consent signature 
and on the Adverse Events page thereafter. Clinically significant findings must be discussed 
with the sponsor.
8.4.6
Immunogenicity
All patients dosed with CLR325 will have blood samples analyzed for antibodies targeting 
CLR325. In addition, cross-reactivity of anti-drug antibodies towards endogenous apelin will 
be assessed. Anti-CLR325 and anti-apelin antibodies will be assessed in serum by an 
immunoassay. Due to the size of CLR325 and apelin, all anti-drug antibodies are expected to 
possess neutralizing capacity. 
The timing of immunogenicity sampling is provided in the Assessment Schedule, and details 
of sample collection are provided in the Laboratory Manual.
All blood samples will be taken by either direct venipuncture (other than the vein used for 
dose administration) or an indwelling cannula inserted in a forearm vein. All samples will be 
given a unique sample number and a collection number (as listed in Blood log within the 
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SOM). The actual sample collection date and time will be entered on the PK blood collection 
page of the source documentation. Sampling problems will be commented in the eCRF system.
8.4.7
Alcohol test and drug screen
Patients will be tested for substances of abuse (e.g., alcohol, amphetamines, barbiturates, 
benzodiazepines, cannabinoids, cocaine, and opiates).
Results will be available as Source data and will not be recorded within the clinical database.
8.4.8
AICD interrogation
If patients have an automatic implantable cardioverter defibrillator (AICD) in place, the 
device will be interrogated at the baseline visit and at the end of study visit to assess any 
arrhythmias that occurred during the entire study period.  The information gathered from the 
interrogation (e.g., number of runs of ventricular tachycardia) will be recorded in the eCRF.
8.4.9
Cardiac Holter and telemetry monitoring
Patients will be connected to a Holter monitor to gather data on heart rate and cardiac 
arrhythmias that occur during the treatment period of the study. The monitoring will begin at 
approximately 1 hour prior to the start of study drug infusion and disconnected prior to 
inpatient discharge. Given the time required to analyze Holter recordings, Holter results will 
not be available to site investigators prior to patient discharge.  However, in addition to Holter 
monitoring, patients will also be monitored via real time cardiac telemetry to allow site staff 
to immediately detect the occurrence of any cardiac arrhythmias.
8.4.10
Fluid input and output
Fluid intake and output during the treatment period will be recorded in the appropriate section 
of the eCRF.
8.5
Pharmacokinetics
Pharmacokinetic (PK) samples will be obtained and evaluated in all subjects. 
Untreated samples (placebo) will not be analyzed. The plasma samples will be analyzed to 
quantify CLR325 using a validated LC-MS/MS method. 
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For standard pharmacokinetic abbreviations and definitions see the list provided at the 
beginning of this protocol. The following pharmacokinetic parameters will be determined 
using the actual recorded sampling times and non-compartmental method(s) with Phoenix 
WinNonlin (Version 6.4 or higher): Cmax, Tmax, AUC0-18h, AUClast, AUC0-28h, AUCinf, 
T1/2, CL (CLR325 only), Vss (CLR325 only), CLr, and Ae0-28 from the plasma 
concentration-time or urine concentration and collection volume data. The renal clearance 
(CLr) will be determined based on AUC and Ae available for the same time period.
The linear trapezoidal rule will be used for AUC calculation. Regression analysis of the 
terminal plasma elimination phase for the determination of T1/2 will include at least 3 data 
points after Cmax. If the adjusted R2 value of the regression analysis of the terminal phase 
will be less than 0.75, no values will be reported for T1/2, AUCinf, Vss (CLR325 only), and 
CL (CLR325 only).
8.5.1
PK blood collection
For details on PK blood collection and processing, labeling, and shipment instructions, see 
laboratory manual. The laboratory manual must be strictly adhered to. PK sample collection 
times are described in the Assessment Schedule. Samples will be collected via syringe that 
will be connected to an i.v. catheter or butterfly needle and transferred into a customized tube 
that will be supplied by the central laboratory. These customized tubes are not sterile and must 
not be filled by direct phlebotomy.
The exact clock time of dosing, as well as actual sample collection date and time will be 
entered on the PK blood collection summary page of the source documentation.   Sampling 
problems will be noted in the relevant field of the source documentation.
8.5.2
PK assessments
See Sample Blood log tables in the Site Operations Manual.
Deviations for the following assessment times are acceptable based on logistical and 
operational considerations:
Table 8-2
Permitted assessment windows
Activity
0hr
Post start of infusion
PK blood collection time-points
Within 60 min prior to start of infusion
± 5 min up to 28 hours
Every effort will be made to take the pharmacokinetic sample at the protocol specified time. 
Other assessments, e.g., ECG, vital signs etc. should be taken after the PK sample.
8.5.3
PK urine collection (28-hour urine collection)
PK urine samples will be collected to assess renal clearance of CLR325 and its active 
metabolite, CQJ295. Twenty-eight (28) hour cumulative urine will be collected post the start 
of the infusion. The urine collected from each voiding will be refrigerated (4°C). The entire 
collection over 28 hours will be made homogenous and the final volume and pH value will be 
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For details on the sample numbering, collection, processing, labeling, and shipment 
instructions, see laboratory manual. The collection period is also described in the 
Assessment Schedule. Relevant sample information will be entered on the PK urine collection 
summary page of the source documentation. Sampling problems will be noted in the relevant 
field of the source documentation.
8.6
Other assessments
No additional tests will be performed on subjects entered into this study.
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9
Safety monitoring
9.1
Adverse events
An adverse event (AE) is any untoward medical occurrence (i.e., any unfavorable and 
unintended sign [including abnormal laboratory findings], symptom or disease) in a subject or 
clinical investigation subject after providing written informed consent for participation in the 
study. Therefore, an AE may or may not be temporally or causally associated with the use of a 
medicinal (investigational) product.
The occurrence of adverse events should be sought by non-directive questioning of the patient
at each visit during the study. Adverse events also may be detected when they are volunteered 
by the patient during or between visits or through physical examination, laboratory test, or 
other assessments.
Abnormal laboratory values or test results constitute adverse events only if they fulfill at least 
one of the following criteria:

they induce clinical signs or symptoms,

they are considered clinically significant,

they require therapy.
Clinically significant abnormal laboratory values or test results should be identified through a 
review of values outside of normal ranges/clinically notable ranges, significant changes from 
baseline or the previous visit, or values which are considered to be non-typical in patients with 
underlying disease. Investigators have the responsibility for managing the safety of individual 
subject and identifying adverse events. Alert ranges for liver related events are included in 
Section 9.3.
Adverse events must be recorded on the Adverse Events eCRF for patients that pass screening 
and enter into the study. The adverse events should be reported according to the signs, 
symptoms or diagnosis associated with them, and accompanied by the following information:
1.
The severity grade AE grade

mild: usually transient in nature and generally not interfering with normal activities

moderate: sufficiently discomforting to interfere with normal activities

severe: prevents normal activities
2.
Its relationship to the study treatment
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3.
Its duration (start and end dates) or if the event is ongoing an outcome of not
recovered/not resolved should be reported.
4.
Whether it constitutes a serious adverse event (SAE). See Section 9.2 for definition of SAE
5.
Action taken regarding study treatment.  All adverse events should be treated
appropriately. Treatment may include one or more of the following:

no action taken (i.e. further observation only)

study treatment dosage adjusted/temporarily interrupted

study treatment permanently discontinued due to this adverse event

concomitant medication given

non-drug therapy given

subject hospitalized/subject’s hospitalization prolonged
6.
Its outcome (not recovered/not resolved; recovered/resolved; recovering/resolving,
recovered/resolved with sequelae; fatal; or unknown)
Once an adverse event is detected, it should be followed until its resolution or until it is 
judged to be permanent, and assessment should be made at each visit (or more frequently, if 
necessary) of any changes in severity, the suspected relationship to the study drug, the 
interventions required to treat it, and the outcome.
Information about common side effects already known about the investigational drug can be 
found in the Investigator Brochure (IB) or will be communicated between IB updates in the 
form of Investigator Notifications. This information will be included in the subject informed 
consent and should be discussed with the subject during the study as needed.
The investigator should also instruct each subject to report any new adverse event (beyond the 
protocol observation period) that the subject, or the subject’s personal physician, believes 
might reasonably be related to study treatment. This information should be recorded in the 
investigator’s source documents, however, if the AE meets the criteria of an SAE, it must be 
reported to Novartis.
9.2
Serious adverse event reporting
9.2.1
Definition of SAE
An SAE is defined as any adverse event (appearance of (or worsening of any pre-existing) 
undesirable sign(s), symptom(s) or medical conditions(s) which meets any one of the 
following criteria:

is fatal or life-threatening

results in persistent or significant disability/incapacity

constitutes a congenital anomaly/birth defect

requires inpatient hospitalization or prolongation of existing hospitalization, unless
hospitalization is for:

routine treatment or monitoring of the studied indication, not associated with any
deterioration in condition (e.g., worsening of heart failure symptoms)

elective or pre-planned treatment for a pre-existing condition that is unrelated to the
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
treatment on an emergency outpatient basis for an event not fulfilling any of the 
definitions of a SAE given above and not resulting in hospital admission

social reasons and respite care in the absence of any deterioration in the patient’s 
general condition

is medically significant, i.e. defined as an event that jeopardizes the subject or may require 
medical or surgical intervention.
Life-threatening in the context of a SAE refers to a reaction in which the subject was at risk of 
death at the time of the reaction; it does not refer to a reaction that hypothetically might have 
caused death if more severe.
All malignant neoplasms will be assessed as serious under “medically significant” if other 
seriousness criteria are not met.
Any suspected transmission via a medicinal product of an infectious agent is also considered a 
serious adverse reaction.
Medical and scientific judgment should be exercised in deciding whether other situations 
should be considered serious reactions, such as important medical events that might not be 
immediately life threatening or result in death or hospitalization but might jeopardize the 
patient or might require intervention to prevent one of the other outcomes listed above. 
Examples of such events are intensive treatment in an emergency room or at home for allergic 
bronchospasm, blood dyscrasias or convulsions that do not result in hospitalization or 
development of dependency or abuse.
All AEs (serious and non-serious) are captured on the CRF, SAEs also require individual 
reporting to DS&E as per Section 9.2.2.
9.2.2
SAE reporting
To ensure patient safety, every SAE, regardless of causality, occurring after the subject has 
provided informed consent and until 30 days after the patient has stopped study participation 
(defined as time of last dose of study drug taken or last visit whichever is the later) must be 
reported to Novartis within 24 hours of learning of its occurrence as described below. 
Any SAEs experienced after this should only be reported to Novartis if the investigator 
suspects a causal relationship to study treatment.
Recurrent episodes, complications, or progression of the initial SAE must be reported as 
follow-up to the original episode, regardless of when the event occurs. This report must be 
submitted within 24 hours of the investigator receiving the follow-up information. An SAE 
that is considered completely unrelated to a previously reported one should be reported 
separately as a new event.
Information about all SAEs (either initial or follow up information) is collected and recorded 
on the paper Serious Adverse Event Report Form. The investigator must assess the 
relationship to each specific component of study treatment (if study treatment consists of 
several drugs) complete the SAE Report Form in English, and send the completed, signed 
form by fax within 24 hours after awareness of the SAE to the local Novartis Drug Safety and 
Epidemiology Department, notifying the Study Lead. Contact information is listed in the 
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The original copy of the SAE Report Form and the fax confirmation sheet must be kept with 
the source documentation at the study site. Follow-up information should be provided using a 
new paper SAE Report Form stating that this is a follow-up to a previously reported SAE.
SAEs (initial and follow-up) that are recorded electronically in the Electronic Data Capture 
system should be entered, saved and e-signed within 24 hours of awareness of the SAE or 
changes to an existing SAE. These data will automatically be submitted to Novartis Drug 
Safety & Epidemiology immediately after investigator signature or 24 hours after entry, 
whichever occurs first. Study site personnel must also inform the Study Lead.
Follow- up information provided should describe whether the event has resolved or continues, 
if and how it was treated, whether the treatment code was broken or not and whether the 
subject continued or withdrew from study participation. Each re-occurrence, complication, or 
progression of the original event should be reported as a follow-up to that event regardless of 
when it occurs.
If the SAE is not previously documented in the Investigator’s Brochure (new occurrence) and 
is thought to be related to the investigational treatment a Drug Safety and Epidemiology 
Department associate may urgently require further information from the investigator for 
Health Authority reporting. Novartis may need to issue an Investigator Notification (IN) to 
inform all investigators involved in any study with the same investigational treatment that this 
SAE has been reported. Suspected Unexpected Serious Adverse Reactions (SUSARs) will be 
collected and reported to the competent authorities and relevant ethics committees in 
accordance with EU Guidance 2011/C 172/01 or as per national regulatory requirements in 
participating countries.
9.3
Liver safety monitoring
To ensure subject safety and enhance reliability in determining the hepatotoxic potential of an 
investigational drug, a standardized process for identification, monitoring and evaluation of 
liver events has to be followed.
The following two categories of abnormalities / adverse events have to be considered during 
the course of the study:

Liver laboratory triggers, which will require repeated assessments of the abnormal
laboratory parameter

Liver events, which will require close observation, follow-up monitoring and completion
of the standard base liver CRF pages
Please refer to Table 9-1 for complete definitions of liver laboratory triggers and liver events.
Every liver laboratory trigger or liver event should be followed up by the investigator or 
designated personal at the trial site, as summarized below and detailed in in Table 9-1.
For the liver laboratory trigger:

Repeating the LFT within the next week to confirm elevation.

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Repeat laboratory tests should be entered on the appropriate unscheduled local laboratory 
CRF page.

If the elevation is confirmed, close observation of the patient will be initiated, including
consideration of treatment interruption if deemed appropriate.
For the liver events:

Repeating the LFT to confirm elevation as appropriate

Discontinuation of the investigational drug (refer to Section 7.1, if appropriate)

Hospitalization of the subject if appropriate

A causality assessment of the liver event via exclusion of alternative causes (e.g. disease,
co-medications)

An investigation of the liver event which needs to be followed until resolution.
These investigations can include serology tests, imaging and pathology assessments, 
hepatologist’s consultancy, based on investigator’s discretion. All follow-up information, and 
the procedures performed should be recorded as appropriate in the CRF, including the liver 
event overview CRF pages.
Table 9-1
Liver Event and Laboratory Trigger Definitions
Definition/ threshold
Liver laboratory 
triggers
3 x ULN < ALT / AST < 5 x ULN
1.5 x ULN < TBL < 2 x ULN
Liver events
ALT or AST > 5 × ULN
ALP > 2 × ULN (in the absence of known bone pathology)
TBL > 2 × ULN (in the absence of known Gilbert syndrome)
ALT or AST > 3 × ULN and INR > 1.5
Potential Hy’s Law cases (defined as ALT or AST > 3 × ULN and TBL > 2 × ULN 
[mainly conjugated fraction] without notable increase in ALP to > 2 × ULN)
Any clinical event of jaundice (or equivalent term)
ALT or AST > 3 × ULN accompanied by (general) malaise, fatigue, abdominal pain, 
nausea, or vomiting, or rash with eosinophilia
Any adverse event potentially indicative of a liver toxicity *

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Table 9-2
Follow Up Requirements for Liver Events and Laboratory Triggers
Criteria
Actions required
Follow-up monitoring
Potential Hy’s Law casea

Discontinue the study drug 
immediately

Hospitalize, if clinically
appropriate

Establish causality

Complete liver CRF
ALT, AST, TBL, Alb, PT/INR, ALP 
and γGT until resolutionc (frequency 
at investigator discretion) 
ALT or AST
> 8 × ULN

Discontinue the study drug
immediately

Hospitalize if clinically
appropriate

Establish causality

Complete liver CRF
ALT, AST, TBL, Alb, PT/INR, ALP 
and γGT until resolutionc (frequency 
at investigator discretion)
> 3 × ULN and INR > 1.5

Discontinue the study drug
immediately

Hospitalize, if clinically
appropriate

Establish causality

Complete liver CRF
ALT, AST, TBL, Alb, PT/INR, ALP 
and γGT until resolutionc (frequency 
at investigator discretion)
> 5 to ≤ 8 × ULN

Repeat LFT within 48 hours

If elevation persists, continue
follow-up monitoring

If elevation persists for more
than 2 weeks, discontinue the
study drug

Establish causality

Complete liver CRF
ALT, AST, TBL, Alb, PT/INR, ALP 
and γGT until resolutionc (frequency 
at investigator discretion)
> 3 × ULN accompanied
by symptomsb

Discontinue the study drug
immediately

Hospitalize if clinically
appropriate

Establish causality

Complete liver CRF
ALT, AST, TBL, Alb, PT/INR, ALP 
and γGT until resolutionc (frequency 
at investigator discretion)
> 3 to ≤ 5 × ULN
(patient is asymptomatic)

Repeat LFT within the next
week

If elevation is confirmed,
initiate close observation of
the patient
Investigator discretion
Monitor LFT within 1 to 4 weeks

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Criteria
Actions required
Follow-up monitoring
ALP (isolated)
> 2 × ULN (in the
absence of known bone
pathology)

Repeat LFT within 48 hours

If elevation persists, establish
causality

Complete liver CRF
Investigator discretion
Monitor LFT within 1 to 4 weeks or 
at next visit
TBL (isolated)
> 2 × ULN (in the
absence of known Gilbert
syndrome)

Repeat LFT within 48 hours

If elevation persists,
discontinue the study drug
immediately

Hospitalize if clinically
appropriate

Establish causality

Complete liver CRF
ALT, AST, TBL, Alb, PT/INR, ALP 
and γGT until resolutionc (frequency 
at investigator discretion)
Test for hemolysis (e.g. 
reticulocytes, haptoglobin, 
unconjugated [indirect] bilirubin)
> 1.5 to ≤ 2 × ULN
(patient is asymptomatic)

Repeat LFT within the next
week

If elevation is confirmed,
initiate close observation of
the patient
Investigator discretion
Monitor LFT within 1 to 4 weeks or 
at next visit
Jaundice

Discontinue the study drug
immediately

Hospitalize the patient

Establish causality

Complete liver CRF
ALT, AST, TBL, Alb, PT/INR, ALP 
and γGT until resolutionc (frequency 
at investigator discretion)
Any AE potentially 
indicative of a liver 
toxicity*

Consider study drug
interruption or discontinuation

Hospitalization if clinically
appropriate

Establish causality

Complete liver CRF
Investigator discretion
*These events cover the following: hepatic failure, fibrosis and cirrhosis, and other liver damage-
related conditions; the non-infectious hepatitis; the benign, malignant and unspecified liver neoplasms
a Elevated ALT/AST > 3 × ULN and TBL > 2 × ULN but without notable increase in ALP to > 2 × ULN
b (General) malaise, fatigue, abdominal pain, nausea, or vomiting, or rash with eosinophilia
c Resolution is defined as an outcome of one of the following: (1) return to baseline values, (2) stable 
values at three subsequent monitoring visits at least 2 weeks apart, (3) remain at elevated level after a 
maximum of 6 months, (4) liver transplantation, and (5) death.

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9.4
Renal safety monitoring
Renal events are defined as one of the following:

confirmed (after ≥ 24h) increase in serum creatinine of ≥ 25% compared to baseline
during normal hydration status

new onset (≥1+) proteinuria, hematuria or glucosuria; or as a

doubling in the urinary albumin-creatinine ratio (ACR) or urinary protein-creatinine ratio
(PCR) (if applicable).
The following two categories of abnormalities/adverse events have to be considered during 
the course of the study:

Serum creatinine triggers that will require follow up and repeat assessments of the
abnormal laboratory parameter

Urine dipstick triggers that will require follow up and repeat assessments of the abnormal
laboratory parameter
Table 9-3
Specific Renal Alert Criteria and Actions
Renal Event
Actions
Serum creatinine increase
25 – 49% compared to baseline
Confirm 25% increase after 24-48h
Follow up within 2-5 days
Serum creatinine increase  ³ 50 % compared to 
baseline
Follow up within 24-48h if possible
Consider drug interruption
Consider patient hospitalization /specialized 
treatment
Albumin- or Protein-creatinine ratio increase ≥2-
fold
Albumin-creatinine ratio (ACR) ≥ 30 mg/g or ≥ 3 
mg/mmol;
New dipstick proteinuria ≥ 1+
Protein-creatinine ratio (PCR )≥ 150 mg/g or >15 
mg/mmol
Confirm value after 24-48h
Perform urine microscopy
Consider drug interruption / discontinuation
New dipstick glucosuria ≥ 1+ not due to diabetes
Blood glucose (fasting)
Perform serum creatinine, ACR
New dipstick hematuria not due to trauma
Urine sediment microscopy
Perform serum creatinine, ACR
Document contributing factors: co-medication, other co-morbid conditions, and additional diagnostic 
procedures performed in the CRF
Monitor patient regularly (frequency at investigator’s discretion) until one of the following:
Event resolution: (sCr within 10% of baseline or protein-creatinine ratio within 50% of baseline)
Event stabilization: sCr level with ±10% variability over last 6 months or protein-creatinine ratio 
stabilization at a new level with ±50% variability over last 6 months.

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9.5
Pregnancy reporting
To ensure patient safety, each pregnancy occurring after signing the informed consent must be 
reported to Novartis within 24 hours of learning of its occurrence. The pregnancy should be 
followed up to determine outcome, including spontaneous or voluntary termination, details of 
the birth, and the presence or absence of any birth defects, congenital abnormalities, or 
maternal and/or newborn complications. The study drug must be discontinued, though the 
patient may stay in the study, if she wishes to do so. All assessments that are considered as a 
risk during pregnancy must not be performed. The patients may continue all other protocol 
assessments.
Pregnancy must be recorded on a Pharmacovigilance Pregnancy Form and reported by the 
investigator to the local Novartis Drug Safety and Epidemiology Department. Pregnancy 
follow-up should be recorded on the same form and should include an assessment of the 
possible relationship to the Novartis study drug of any pregnancy outcome. Any SAE 
experienced during pregnancy must be reported on an SAE Report Form.
Pregnancy outcomes must be collected for the female partners of any males who took study 
treatment in this study. Consent to report information regarding these pregnancy outcomes 
should be obtained from the mother. (Prepare and submit for EC/IRB approval the ICF to 
cover this with the main study ICFs).
Procedures to be followed in this case are described in the attached link:
Link to Guideline on Prevention of Pregnancies in Clinical Trials (go/CSSG)
9.6
Prospective suicidality assessment
Not applicable.
9.7
Early phase safety monitoring
The Investigator will monitor adverse events in an ongoing manner and inform the Sponsor of 
any clinically relevant observations. Any required safety reviews will be made jointly 
between medically qualified personnel representing the
Sponsor and Investigator. 
Such evaluations may occur verbally, but the outcome and key discussion points will be 
summarized in writing (e-mail) and made available to both Sponsor and all Investigator(s). 
Criteria pertaining to stopping the study/treatment or adapting the study design are presented 
above.
When two or more clinical site(s) are participating in the clinical study, the Sponsor will 
advise the Investigator(s) at all sites in writing (e-mail) (and by telephone if possible) of any 
new, clinically relevant safety information reported from another site during the conduct of 
the study in a timely manner.

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10
Data review and database management
10.1
Site monitoring
Before study initiation, at a site initiation visit or at an investigator’s meeting, a Novartis 
representative will review the protocol and CRFs with the investigators and their staff. 
During the study Novartis employs several methods of ensuring protocol and GCP 
compliance and the quality/integrity of the sites’ data. The monitor will visit the site to check 
the completeness of patients records, the accuracy of entries on the CRFs, the adherence to the 
protocol and to Good Clinical Practice, the progress of enrollment, and to ensure that study 
drug is being stored, dispensed, and accounted for according to specifications. Key study 
personnel must be available to assist the monitor during these visits.
10.2
Data collection
Designated investigator staff will enter the data required by the protocol into the Electronic 
Case Report Forms using fully validated software that conforms to 21 CFR Part 11 
requirements. Designated investigator site staff will not be given access to the EDC system 
until they have been trained. Automatic validation programs check for data discrepancies and, 
by generating appropriate error messages, allow the data to be confirmed or corrected before 
transfer of the data to CMED clinical database, Timaeus. The Investigator must certify that 
the data entered into the Electronic Case Report Forms are complete and accurate. 
After database lock, the investigator will receive a CD-ROM or paper copies of the subject 
data for archiving at the investigational site.
Data not requiring a separate written record will be defined in the Site Operations Manual and 
assessment schedule and can be recorded directly on the CRFs. All other data captured for this 
study will have an external originating source (either written or electronic) with the CRF not 
being considered as source.
10.3
Database management and quality control
All data should be recorded, handled and stored in a way that allows its accurate reporting, 
interpretation and verification.
CMED Data Management review the data entered into the eCRFs by investigational staff for 
completeness and accuracy and instruct the site personnel to make any required corrections or 
additions. Queries are sent to the investigational site using an electronic data query. 
Designated investigator site staff is required to respond to the query and confirm or correct the 
data. 
Concomitant medications entered into the database will be coded using the WHO Drug 
Reference List, which employs the Anatomical Therapeutic Chemical classification system. 
Medical history/current medical conditions and adverse events will be coded using the 
Medical dictionary for regulatory activities (MedDRA) terminology.
Select laboratory samples will be processed centrally and the results will be sent electronically 
to Novartis (or a designated CRO)

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Holter data will be processed centrally and results will be sent electronically to Novartis 
(or designated CRO).
For echocardiograms, a dedicated imaging CRO will collect all echo data from the sites and 
send for quantitative analysis to a blinded expert reader.  The analysis results will then be 
collected by the imaging CRO and transformed into a Novartis format defined by a data 
transfer specification.  The transformed output will then be sent to Novartis data management 
for incorporation into the Clinical Study Report (CSR).  The imaging CRO will be responsible 
for all image data clarification forms and missing data at all sites. 
At the conclusion of the study, the occurrence of any emergency code breaks will be 
determined after return of all code break reports and unused drug supplies to Novartis.
10.4
Data Monitoring Committee
Not required.
10.5
Adjudication Committee
Not required
11
Data analysis
Data analyses will be conducted under the supervision of Novartis personnel.
11.1
Analysis sets
For all analysis sets, subjects will be analyzed according to the study treatment(s) received.
The full analysis set will include all subjects that received any study drug or placebo.
The safety analysis set will be the same as the full analysis set.
The primary PK analysis set will include all subjects with available PK data. The secondary 
PK analysis set will include all subjects with available PK data and no protocol deviations 
with relevant impact on PK data.
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11.2
Subject demographics and other baseline characteristics
All data for background and demographic variables will be listed by treatment group and 
subject. Summary statistics will be provided by treatment group.
Relevant medical history, current medical conditions, results of laboratory screens, drug tests 
and any other relevant information will be listed by treatment group and subject.
11.3
Treatments (study drug, rescue medication, other concomitant 
therapies, compliance)
Data for total dose of infusion, infusion rate and total time of infusion will be listed by 
treatment group and subject.
Data for concomitant therapies will be listed by treatment group and subject.
11.4
Analysis of the primary variable(s)
The primary analyses for this study will characterize the safety of 18 hour infusion of 
CLR325 in patients with stableheart failure.
11.4.1
Variable(s)
The primary variable with be the occurrence of adverse events in patients in the study.  
11.4.2
Statistical model, hypothesis, and method of analysis
All information obtained on adverse events will be displayed by treatment and subject.
The number and percentage of subjects with adverse events will be tabulated by body system 
and preferred term with a breakdown by treatment. A subject with multiple adverse events 
within a body system is only counted once towards the total of this body system.
The occurrence of adverse events will be examined by treatment.  Both the total number of adverse 
events, and the preferred term for the adverse event will be compared by treatment group.
It is hypothesized that the estimated rate of serious adverse events in the treated group equal 
to that in the placebo group.  The estimated probability of serious adverse events will be 
examined with 90% confidence limits around the estimated probability. Summary tables with 
the number, percentage, and severity of adverse events will be provided to assess safety and 
tolerability per treatment groups. The number and percentage of patients with adverse events 
will be tabulated by body system and preferred term with a breakdown by treatment group. 
The difference in the occurrence of adverse effects will be quantified by using the Fisher's 
Exact Test.  Separate tables and listings will be presented indicating event severity and study 
drug relationship. All safety laboratory and other continuous data will be listed, and 
descriptive statistics will be generated.
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All data for vital signs, cardiac monitoring, ECG evaluations, hematology, blood chemistry 
and urinalysis will be listed for each subject and summarized by descriptive statistics per 
treatment and for time interval where appropriate. For all these safety variables, if ranges are 
available, abnormalities will be flagged. The individual data and descriptive statistics will be 
also shown as graphical outputs. Cardiac monitoring data will be listed and descriptive statistics 
generated by treatment and time. Graphical presentations will be generated to show the individual 
time course of the data, including concentration-response plots.
Pharmacokinetic results will be summarized by descriptive statistics per treatment.
11.4.3
Handling of missing values/censoring/discontinuations
All drug concentrations below the lower limit of quantification (LLOQ) will be reported as 
“zero” and will be treated as zero for calculation of PK parameters.
11.4.4
Supportive analyses
Not applicable.
11.5
Analysis of secondary and exploratory variables
11.5.2
Safety
Vital signs
All vital signs data will be listed by treatment, subject, and visit/time and if ranges are 
available abnormalities (and relevant orthostatic changes) will be flagged. Summary statistics 
will be provided by treatment and visit/time.
ECG evaluations
All ECG data will be listed by treatment, subject and visit/time, abnormalities will be flagged. 
Summary statistics will be provided by treatment and visit/time.
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Clinical laboratory evaluations
All laboratory data will be listed by treatment, subject, and visit/time and if normal ranges are 
available abnormalities will be flagged. Summary statistics will be provided by treatment and 
visit/time.  The values of the laboratory evaluations will be compared by treatment.
Adverse events
All information obtained on adverse events will be displayed by treatment and subject.
The number and percentage of subjects with adverse events will be tabulated by body system 
and preferred term with a breakdown by treatment. A subject with multiple adverse events 
within a body system is only counted once towards the total of this body system.
The occurrence of adverse events will be examined by treatment. Both the total number of 
adverse events, and the preferred term for the adverse event will be compared by treatment 
group.
Other safety evaluations
Graphs of cardiac and safety variables will be produced by time from baseline to the end of 
treatment (hour 28).
Immunogenicity
All immunogenicity results will be listed by subject and visit/time.
11.5.3
Pharmacokinetics
CLR325 plasma concentration data will be listed by treatment, subject, and visit/sampling 
time point. Descriptive summary statistics will be provided by treatment and visit/sampling 
time point, including the frequency (n, %) of concentrations below the LLOQ and reported as 
zero.
Summary statistics will include mean (arithmetic and geometric), SD, CV (arithmetic and 
geometric), median, minimum and maximum. An exception to this is Tmax where median, 
minimum and maximum will be presented. Concentrations below LLOQ will be treated as 
zero in summary statistics and for PK parameter calculations. A geometric mean will not be 
reported if the dataset includes zero values. Pharmacokinetic parameters will be calculated as 
described in Section 8.5 and will be listed by treatment and subject.
11.5.4
Pharmacokinetic / pharmacodynamic interactions
Not applicable.

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11.5.5
Other assessments
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11.5.5.2 Immunogenicity
Anti-CLR325 and anti-apelin antibodies in serum will be analyzed pre-dose, day 10 and 
day 28. Summary statistics will be provided for anti-CLR325 and anti-apelin antibodies. 
Immunogenicity will be reported using the binary assessment “Yes” or “No”. For 
immunogenicity positive samples (“Yes”), the corresponding titer will be reported.
11.6
Sample size calculation
The sample size is based on clinical considerations for safety review of this study. With 6 
active subjects in a dose cohort, there is a 74% chance of at least one subject having a 
particular adverse event when the event rate is 20%. With 4 active subjects in a dose cohort, 
this chance is 60%.
11.7
Power for analysis of key secondary variables
Not applicable.
12
Ethical considerations
12.1
Regulatory and ethical compliance
This clinical study was designed and shall be implemented and reported in accordance with 
the ICH Harmonized Tripartite Guidelines for Good Clinical Practice, with applicable local 
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regulations (including European Directive 2001/20/EC, US Code of Federal Regulations Title 
21, and Japanese Ministry of Health, Labor, and Welfare), and with the ethical principles laid 
down in the Declaration of Helsinki.
12.2
Responsibilities of the investigator and IRB/IEC
Before initiating a trial, the investigator/institution should obtain approval/favorable opinion 
from the Institutional Review Board/Independent Ethics Committee (IRB/IEC) for the trial 
protocol, written informed consent form, consent form updates, subject recruitment 
procedures (e.g. advertisements) and any other written information to be provided to subjects. 
Prior to study start, the investigator is required to sign a protocol signature page confirming 
his/her agreement to conduct the study in accordance with these documents and all of the 
instructions and procedures found in this protocol and to give access to all relevant data and 
records to Novartis monitors, auditors, Novartis Quality Assurance representatives, designated 
agents of Novartis, IRBs/IECs, and regulatory authorities as required. If an inspection of the 
clinical site is requested by a regulatory authority, the investigator must inform Novartis 
immediately that this request has been made.
For multi-center trials, a Coordinating Investigator will be selected by Novartis around the 
time of Last Patient Last Visit to be a reviewer and signatory for the clinical study report. 
12.3
Publication of study protocol and results
Novartis assures that the key design elements of this protocol will be posted in a publicly 
accessible database such as clinicaltrials.gov. In addition, upon study completion and 
finalization of the study report the results of this trial will be either submitted for publication 
and/or posted in a publicly accessible database of clinical trial results.
13
Protocol adherence
This protocol defines the study objectives, the study procedures and the data to be collected 
on study participants. Additional assessments required to ensure safety of subjects should be 
administered as deemed necessary on a case by case basis. Under no circumstances should an 
investigator collect additional data or conduct any additional procedures for any research 
related purpose involving any investigational drugs.
Investigators must apply due diligence to avoid protocol deviations. If the investigator feels a 
protocol deviation would improve the conduct of the study this must be considered a protocol 
amendment, and unless such an amendment is agreed upon by Novartis and approved by the 
IRB/IEC/REB it cannot be implemented. All significant protocol deviations will be recorded 
and reported in the CSR.
13.1
Protocol Amendments
Any change or addition to the protocol can only be made in a written protocol amendment that 
must be approved by Novartis, Health Authorities where required, and the IRB/IEC prior to 
implementation.

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Only amendments that are intended to eliminate an apparent immediate hazard to subjects 
may be implemented, provided the Health Authorities and the reviewing IRB/IEC are 
subsequently notified by protocol amendment.
Notwithstanding the need for approval of formal protocol amendments, the investigator is 
expected to take any immediate action required for the safety of any subject included in this 
study, even if this action represents a deviation from the protocol. In such cases, the Study 
Lead should be informed and (serious) adverse event reporting requirements (Section 9) 
followed as appropriate.

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14
References
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cardiac contractility and reduces cardiac loading in vivo. Cardiovasc. Res. p. 73-82.
Barnes GD, Alam S, Carter G, et al. (2013) Sustained cardiovascular actions of APJ agonism 
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482-91.
Binanay C, Califf RM, Hasselblad V, et al. (2005) Evaluation study of congestive heart failure 
and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA p. 1625-33.
Chong KS, Gardner RS, Morton JJ, et al. (2006) Plasma concentrations of the novel peptide 
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Digitalis Investigation Group (1997) The effect of digoxin on mortality and morbidity in 
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agent for decompensated heart failure. Am. Heart J. p. 932-3
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Japp AG, Cruden NL, Barnes G, et al. (2010) Acute cardiovascular effects of apelin in 
humans: potential role in patients with chronic heart failure. Circulation p. 1818-27.
Jong P, Vowinckel E, Liu PP, et al. (2002) Prognosis and determinants of survival in patients 
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Kuba K, Zhang L, Imai Y, et al. (2007) Impaired heart contractility in Apelin gene-deficient 
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Nagueh, AF, Middleton, KJ, Kopelen, HA, et al. (1997) Doppler tissue imaging: a
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O'Carroll AM, Lolait SJ, Harris LE, et al. (2013) The apelin receptor APJ: journey from an 
orphan to a multifaceted regulator of homeostasis. J. Endocrinol. p. R13-35.
Yang, P, Maguire, JT, and Davenport, AP (2015) Apelin, Elabela/Toddler, and biased 
agonists as novel therapeutic agents in the cardiovascular system. Trends in Pharmacological
Sciences p. 560-567.

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Zhen EY, Higgs RE, Gutierrez JA (2013) Pyroglutamyl apelin-13 identified as the major 
apelin isoform in human plasma. Anal. Biochem. p. 1-9.