A Double-blind, Placebo-controlled, Randomized Study Examining the Effects of Nebivolol Compared to Atenolol on Endothelial Function and Cardiovascular Risk in Patients With Early Vascular Disease
Phase: PHASE2
Conditions: Hypertension
Sponsor: University of Minnesota

 
 
 
 
 
A double-blind, placebo-controlled, randomized study 
examining the effects of nebivolol compared to atenolol on 
endothelial function and cardiovascular risk in patients with 
early vascular disease. 
 
 
 
EVIDENCE: Early Vascular Impairment-Determine Efficacy of Nebivolol, 
Comparator Examination 
 
 
 
 
Principal Investigator: Jay N. Cohn, MD 
 
 
        Co-Investigators: Daniel Duprez, MD, PhD 
 
  
 
 
 
 
Gary Francis, MD 
 
 
 
 
 
 
Sara M. Saul, PhD  
 
 
 
 
    Version Date:   January 14, 2014 
 
 
 
 
University of Minnesota Medical School, Cardiology Division 
 
 
 
 
PI Contact Information: 
Mail: 420 Delaware Street SE, MMC 508 
Minneapolis, MN 55455 
 
Phone: 612-625-5646 
Fax:  612-624-2174 
e-mail: cohnx001@umn.edu 
 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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Table of Contents 
 
 
STUDY SCHEMA .................................................................................................................................. 3 
1. 
INTRODUCTION AND SCIENTIFIC RATIONALE ................................................................. 4 
2. 
STUDY DESIGN ........................................................................................................................... 4 
3. 
METHODOLOGY ........................................................................................................................ 4 
4. 
OBJECTIVES ............................................................................................................................... 5 
5. 
SELECTION OF PATIENTS ....................................................................................................... 6 
6. 
RANDOMIZATION PROCEDURES .......................................................................................... 7 
7. 
TREATMENT PLAN .................................................................................................................... 8 
8. 
STUDY PARAMETERS ............................................................................................................. 10 
9. 
STUDY ENDPOINTS ................................................................................................................. 12 
10.    ADVERSE EVENT REPORTING ............................................................................................. 13 
11.    DATA AND SAFETY MONITORING PLAN ........................................................................... 16 
12.    STATISTICAL CONSIDERATIONS ........................................................................................ 16 
13.    ADMINISTRATIVE REQUIREMENTS ................................................................................... 17 
14.    REFERENCES ............................................................................................................................ 18  
 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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STUDY SCHEMA 
Study Population: 
 
 Males and females between 18 and 80 years of age with early vascular 
disease 
 Borderline blood pressure (120-145/80-90 mm Hg) 
 Borderline or abnormal small artery elasticity (C2) as measured by pulse 
contour analysis  
 Treatment-naïve for all blood pressure medications including diuretics for at 
least 30 days prior to baseline visit 
 No known history of cardiovascular disease 
 
Accrual Goals: 
75 patients enrolled. 
 
Treatment Plan: 
 
 
Schedule of Assessments: 
 Blood pressure at rest at 0, 1, 3, 6 and 9 months 
 Small artery elasticity (C2) and flow-mediated dilation at 0, 1, 3 and 9 
months 
 Rasmussen Disease Score assessments (large artery elasticity, carotid 
intima-medial thickness, electrocardiogram (ECG), treadmill exercise test 
and  left ventricle ultrasound) at  0, 3 and 9 months 
 Cardiac Health Biomarkers (Total cholesterol, LDL, HDL, triglycerides, 
glucose, hsCRP, microalbuminuria and NT-proBNP) at 0, 3 and 9 months 
R
A
N
D
O
M 
I 
Z
E 
 
Arm 2:   
Atenolol 25 mg  
Continue for 1 month 
 
 
Arm 1:   
Nebivolol 5 mg  
Continue for 1 month 
 
 
Arm 3:   
Placebo 
Continue for 1 month 
 
DOSE TITRATION 
 
Arm 1: Nebivolol 10 mg 
Arm 2: Atenolol 50 mg 
Arm 3:“High dose” Placebo  
 
Continue for 8 months 
 
*dose may be returned to initiation 
levels if side effects occur 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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1. INTRODUCTION AND SCIENTIFIC RATIONALE 
 
β-blockers have been widely used for the treatment and prevention of 
cardiovascular disease for more than three decades   In recent years, β-blocker 
usage has declined as studies have shown that traditional β-blockers have little 
effect on peripheral resistance, which is increased in individuals with endothelial 
(vascular) dysfunction [1-3].  Recently, nebivolol, a third generation β-blocker, 
was approved for use in the United States.   
 
Nebivolol is a highly selective β1-blocker with vasodilating effects that reduce 
peripheral resistance.  Vasodilation is mediated by nebivolol’s action at multiple 
points in the nitric oxide (NO) pathway [4].  The NO-mediated vasodilation of 
nebivolol is novel among β-blockers and is particularly promising as impaired 
vascular function in patients with cardiovascular disease may be due in part to 
decreased endothelial NO bioavailability [5].  Studies in patients with 
hypertension and/or coronary artery disease have shown that nebivolol improves 
endothelial function while non-vasodilating β-blockers do not [6, 7].  The efficacy 
of nebivolol on endothelial function in low to moderate risk populations has not 
been well documented.  
 
We propose to study nebivolol in subjects with early vascular disease, using 
atenolol as an active comparator, as both drugs are selective β1-blockers with no 
α-blocking capabilities.  These drugs differ in the fact that atenolol does not have 
vasodilating properties [6]. We hypothesize that both drugs will likely lower blood 
pressure through β1-receptor blocking but only nebivolol will improve impaired 
endothelial function, presumably through NO-mediated vasodilation.  A placebo 
arm will also be employed to further differentiate these two treatment strategies.  
 
2. STUDY DESIGN 
 
This is a randomized, double-blind, placebo-controlled study comparing the 
efficacy of nebivolol and atenolol at improving small artery elasticity and reducing 
cardiovascular disease risk in subjects with early vascular disease.  
Approximately 75 subjects with borderline/elevated blood pressures and impaired 
endothelial function, as measured by arterial elasticity scores, will be recruited 
and assigned to treatment groups using a block randomization scheme.  Patients 
will be randomly allocated to nebivolol, atenolol or placebo, and then followed for 
9 months.  
 
3. METHODOLOGY 
 
The Rasmussen Disease Score (RDS) test panel is the chosen methodology for 
this study.  The 10 parameters of the RDS were selected because of their ability 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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to quantify early structural and functional abnormalities in the vasculature and left 
ventricle which appear long before cardiovascular disease is present [8].   
 
The RDS tests include: large and small artery elasticity (measured by pulse 
contour analysis), resting blood pressure, mild treadmill exercise test, carotid 
IMT, left ventricle mass, ECG, retinal vasculature evaluation, as well as 
quantification of serum NT-proBNP, and microalbuminuria.  Please see Section 8 
for a more detailed description of these parameters.  Quantitative results from 
these tests are converted into categorical classifications based on values 
stratified by age and gender when appropriate.  The categorical data is scored as 
follows: normal = 0 points, borderline = 1 point, abnormal = 2 points.  Point 
values from all parameters are summed to create the RDS, with values ranging 
from 0-20.  Scores of 0-2 are classified as normal, 3-5 as early disease, and 6+ 
as advanced disease.  Previous research has shown that the RDS is a powerful 
predictor of future cardiovascular events [9].   
 
The small artery elasticity (C2) parameter is of particular interest as it is 
responsive to changes in NO levels [10] and is an effective and reliable predictor 
of future hypertension [11] and other cardiovascular events [12].  Changes in C2 
will serve as the primary outcome of this study.  Similar studies using anti-
hypertensive or lipid-lowering interventions have found significant improvements 
in C2 values [13, 14]. 
 
Brachial artery flow-mediated dilation (FMD) measurements will also be 
measured as an index of endothelial function [15], although this method appears 
to be less sensitive to functional changes related to NO bioavailability than C2 
[10].  Utilizing both FMD and C2 will allow comparison with previous studies and 
take advantage of a large sample size to further examine the relative sensitivity 
of each method for reliably measuring endothelial dysfunction. 
 
The duration of intervention for this study is 9 months which is the minimum time 
to adequately detect improvement in left ventricle (LV) mass values.  LV mass 
measurements are a critical component of a comprehensive assessment of 
cardiovascular health and have improved within this temporal window as a result 
of anti-hypertensive intervention [14, 16].  
 
4. OBJECTIVES 
4.1. Primary Objective 
This study will compare the effects of nebivolol against atenolol and 
placebo on endothelial function.  Endothelial function will be measured by 
pulse contour analysis of the small arteries and scored in terms of arterial 
elasticity over a 9 month study period. 
 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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4.2. Secondary Objectives 
4.2.1 Evaluate the effects of nebivolol as compared to atenolol and 
placebo on cardiovascular health in subjects with early vascular 
disease as measured by change in Rasmussen Disease Score 
(RDS) over a 9 month study period. 
 
4.2.2 Evaluate changes in each RDS component over the 9 month study 
period in all treatment groups. 
 
4.2.3 Evaluate the changes in risk factor and biomarker measurements 
from baseline to 3 and 9 month time points in all treatment groups. 
 
4.2.4 Compare the sensitivity of pulse contour analysis and flow-
mediated dilation methodologies for measuring functional changes 
in the endothelium and quantifying endothelial dysfunction. 
 
5. SELECTION OF PATIENTS 
 
Study entry is open to patients regardless of gender or ethnic background.  
Patients will be recruited from the Rasmussen Center for Cardiovascular Disease 
Prevention at the University of Minnesota, Fairview Clinics, and through 
advertisements or flyers posted at the University of Minnesota and surrounding 
communities.   
 
5.1 
Inclusion criteria 
 Males and females 18-80 years of age  
 Borderline blood pressure (120-145/80-90 mm Hg) 
 Borderline or abnormal small artery elasticity (C2) as measured 
by pulse contour analysis  
 Treatment-naïve for all blood pressure medications including 
diuretics for at least 30 days prior to baseline visit 
 Able to walk on a treadmill for 3 minutes 
 Female patients with reproductive potential must use an 
approved contraceptive method if appropriate (for example, 
intrauterine device [IUD], birth control pills, or barrier device) 
during and for 1 month after the last dose of study drug.   
 Voluntary written informed consent before performance of any 
study-related procedure not part of normal medical care, with 
the understanding that consent may be withdrawn by the 
subject at any time without prejudice to future medical care. 
 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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5.2 
Exclusion criteria 
 History of intolerance to β-blockers or clear contraindications to 
their use 
 Current pharmaceutical treatment of blood pressure  
 Known history of cardiovascular disease (myocardial infarction, 
coronary artery bypass graft, unstable angina, uncontrolled 
arrhythmias, stroke, etc.) 
 Known history of diabetes 
 Known history of hepatic, renal, or gastrointestinal disorder 
 Known history of any illness that may cause additional risk (as 
determined by study investigator) 
 Pregnant or lactating women.  When used during pregnancy, β-
blockers may cause fetal harm. 
 Participation in a concomitant clinical trial 
5.3 
Concomitant Therapy 
Concomitant medications may include aspirin, birth control pills, 
lipid lowering agents, anti-platelet medications, psychotropic 
agents, vitamins or warfarin.  The following medications may not be 
taken during the trial:  
 
 Anti-hypertensive medications 
 Vasoactive medications 
 Cardiac medications (including ß-blockers) 
 
Since statins are known to positively influence arterial elasticity, it is 
necessary to control their use.  Any study subject taking statins 
must be on a stable dose for 8 weeks prior to the baseline visit.  
This time window was chosen based on a previous study 
examining the effects of statin combined with an anti-hypertensive 
medication on C2 [13].  There was not a significant improvement in 
C2 between the 8 week and 28 week time points in the groups 
receiving a statin.   
 
Subjects will be instructed to maintain their established statin 
regimen throughout the duration of the study.    
 
6. RANDOMIZATION PROCEDURES 
Randomization will occur after informed consent has been obtained and after 
eligibility is confirmed by measuring blood pressure and small artery elasticity.  
Two 1:1:1 randomization lists (one for subjects taking a statin and one for 
subjects without statin therapy) generated by variable block randomization will be 
used to assign each subject to a study arm at the time of enrollment.  This 
method will allow stratification of statin therapy. 
 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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7. TREATMENT PLAN 
 
7.1 Administration Schedule 
 
Depending on assigned treatment group, subjects will take 
nebivolol, atenolol, or placebo.  Matching medications necessary 
for maintaining the double-blind nature of the study will be provided 
by Forest, Inc. 
 
Nebivolol 5 mg will be taken once daily with or without food by 
mouth for the first month.  At the 1 month visit, nebivolol will be 
increased to10 mg per day and will be taken for up to 8 months. 
 
Atenolol 25 mg will be taken once daily with or without food by 
mouth for the first month.  At the 1 month visit, atenolol will be 
increased to 50 mg per day and will be taken for up to 8 months. 
 
Placebo will be taken in the same manner as nebivolol and 
atenolol treatment groups.  
 
Patients will return to clinic at 1, 3, 6 and 9 months (+/- 1 week) for 
evaluation and a compliance check.   
 
Patients will be instructed to return all study drug bottles and any 
remaining tablets to each appointment where subject compliance 
will be assessed by performing tablet counts.   
 
Patients who demonstrate non-compliance during the study will be 
counseled regarding proper administration of study medication.  In 
cases of continued and/or extreme non-compliance, study 
participation may be discontinued.   
 
7.2 Dose Modification 
 
If subjects develop intolerable side effects during the study, the 
investigator may down-titrate to the starting dose with patient 
permission. 
 
7.3 Study Drug Dispensing 
Study medications and placebos will be dispensed by the University 
of Minnesota Medical Center, Fairview Investigational Drug Service 
(IDS) according to the specified blinded randomization protocol at 
the baseline, 1 month, 3 month and 6 month visits.  Study patients 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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who drop out prior to the 3 month time point will be replaced by 
alternate patients who meet study criteria and will not toward 
overall enrollment goal.  Each patient will receive one bottle of 
study medication or placebo, labeled according to applicable 
regulatory requirements. 
 
7.4 Emergency Treatment Unblinding 
The IDS pharmacist will have the ability to unblind for individual 
patients only in case of an emergency where the further treatment 
of the patient is dependent upon knowing the study medication that 
the patient has been receiving.  In the event of pregnancy, the 
patient’s treatment assignment will be unblinded due to the 
potential effect of active medication on the developing fetus. 
 
7.5 Supportive Care Guidelines 
All supportive measures consistent with optimal patient care will be 
given throughout the study.  
 
7.6 Duration of Therapy 
Patients will receive protocol therapy for 9 months unless any of the 
following occurs: 
 
Patient withdraws consent, 
 
Continued and/or extreme non-compliance, 
 
Intercurrent illness that prevents further administration of study 
drugs, 
 
Study physician feels study treatment is not in the best interest 
of the patient, 
 
Unacceptable adverse events(s). 
 
7.7 Follow-up 
Subjects not experiencing adverse events will be considered 
completed at the 9 month study visit.  For patients experiencing 
adverse events or if treatment related toxicity is present at the final 
visit, an additional follow-up visit will occur in 30 days (± one week). 
Patients may continue on treatment beyond study using 
commercially available drug(s) at the discretion of the treating 
physician; however drug assignment will not be unblinded until the 
last patient completes study drug treatment. 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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8. STUDY PARAMETERS 
8.1 
Schedule of Events 
 
Procedure/measurement 
Screen 
Baseline 
1 
Month 
3 
Months 
6 
Months 
9 
Months 
Resting blood pressure 
x 
 
x 
x 
x 
x 
Arterial elasticity  
(small and large) 
x 
 
x 
x 
  
x 
Treadmill exercise test 
 
x 
  
x 
  
x 
Carotid intima-medial 
thickness 
 
x 
  
x 
  
x 
Electrocardiogram 
 
x 
  
x 
  
x 
Left ventricle ultrasound 
 
x 
  
x 
  
x 
Retinal photo 
 
x 
  
x 
  
x 
Flow-mediated dilation 
 
x 
x 
x 
  
x 
Blood draw 
 
x 
  
x 
  
x 
Urine sample collection 
 
x 
  
x 
  
x 
Physical examination 
 
x 
  
x 
  
x 
Medical history 
 
x 
  
  
  
  
 
 
 
 
 
 
 
 
 
Blood and urine analysis 
Code 
Baseline 
1 
Month 
3 
Months 
6 
Months 
9 
Months 
Pro-brain natriuretic peptide 
ProBNP 
x 
  
x 
  
x 
Microalbumin, urine 
UMA 
x 
  
x 
  
x 
high sensitivity C-reactive 
protein  
hsCRP 
x 
  
x 
  
x 
Lipid panel 
BLIP 
x 
  
x 
  
x 
Fasting glucose 
Glu 
x 
  
x 
  
x 
Urine pregnancy test (if 
appropriate) 
HCGU 
x 
  
  
  
  
 
 
 
 
8.2 
Description of Study Parameters 
 
Resting Blood Pressure: Sitting blood pressure (BP) is measured 
by standard sphygmomanometry at rest.  Blood pressure will be 
measured 4 times on each arm and averaged.  The arm with the 
highest average will be used to obtain future resting blood pressure 
values.  

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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Small and Large Artery Elasticity: Radial artery pulse waves are 
registered with the CV Profiler (Hypertension Diagnostics, Eagan, 
Minnesota). Small artery (C2) and large artery (C1) elasticity are 
derived from the pulse contour analysis. 
 
Treadmill Exercise Test: 
Standing blood pressure is measured before exercise, at the end of 
a 3-minute workload at 5 METS on the basis of a treadmill speed of 
2.3 mph at a slope of 7%, and after a 1-minute recovery period. 
 
Carotid Intimal-Media Thickness: Ultrasound with a Sonosite 
MicroMaxx unit is employed to measure intimal-media thickness 1 
cm distal to the carotid bulb and to identify localized carotid 
plaques. 
 
Electrocardiogram: A standard 12-lead electrocardiogram is 
evaluated for evidence of hypertrophy, repolarization abnormalities, 
or conduction abnormalities. 
 
Left Ventricular Mass Index: Left ventricular (LV) ultrasound is 
performed with Sonosite ultrasound equipment, and left ventricular 
mass index (LVMI) is calculated according the formula of Devereux. 
 
Optic Fundus Photo: A retinal photo of each eye will be acquired 
using a digital camera.  Each photo will be used to measure and 
record vascular structure in the retina. 
 
Flow-Mediated Dilation:  Endothelium-dependent flow-mediated 
dilation (FMD) of the right brachial artery will be measured using a 
SonoSite MicroMaxx ultrasound unit.  Reactive hyperemia will be 
induced by inflation of a blood pressure cuff on the forearm for 5 
minutes.  The brachial artery will be scanned continuously in M-
mode 30s before and 90s after cuff deflation.  These recorded 
images will be used to obtain artery diameter measurements and 
compared to a scan taken during resting conditions.  This 
procedure will be repeated after a 10 minute recovery period and 
the measurements will be averaged. 
 
Blood and Urine Analysis: Blood and urine samples will be tested 
by Fairview Diagnostic Laboratory at the University of Minnesota.  
Fairview Labs normal and abnormal test ranges will be used to 
evaluate test results. 
 
Physical Examination: A study physician will perform a standard 
physical examination to assess the general health of the subject.  

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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Medical History:  Each subject will be asked questions pertaining 
to their own and familial medical history.  Special care will be used 
to collect any information related to cardiovascular events and risk 
factors. 
 
9. STUDY ENDPOINTS 
9.1  
Primary Endpoint  
Change in small artery elasticity (a marker for endothelial function) 
from baseline to 9 months after intervention initiation.   
 
9.2  
Secondary Endpoints 
9.2.1 Change in Rasmussen Disease Score (RDS) from baseline 
to 9 months after intervention initiation.  Each test is scored 
as 0 for normal, 1 for borderline, and 2 for abnormal.  The 
criteria for normal, borderline, and abnormal has been 
established on the basis of large public databases.  The ten 
cardiovascular tests provide total scores ranging from 0 (low 
risk) to 20 (high risk). 
 
 
9.2.2 Change in each of the CDS components as measured from 
baseline to 3 and 9 months. 
 Blood pressure at rest 
 Large artery elasticity 
 Treadmill exercise test 
 Carotid intima-medial thickness 
 Electrocardiogram (ECG) 
 Left ventricle ultrasound 
 Retinal vasculature 
 Microalbuminuria 
 NT-proBNP 
 
9.2.3 Change in risk factor and biomarker measurements as 
measured from baseline to 3 and 9 months. 
 Total cholesterol, LDL, HDL, and triglycerides 
 hsCRP 
 blood glucose 
 
9.2.4 Difference in endothelial function quantification and 
sensitivity to change between pulse contour analysis and 
flow-mediated dilation from baseline to 9 months after 
intervention initiation. 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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10. 
ADVERSE EVENT REPORTING 
For serious adverse event reporting purposes, toxicity information will be 
collected beginning with the 1st dose of study drug and continuing to 
approximately 30 days after the last dose of study drug or at the time the 
patient switches to commercially available drug (if patient decides to 
continue treatment beyond 1 year off study). 
10.1 
Definitions 
Federal regulations [45CFR46.103(b)(5) and 21CFR56.108(b)(1)] 
require the IRB to ensure that researchers promptly report “any 
unanticipated problems involving risk to subjects or others” 
(UPIRTSOs).  The IRB defines a UPIRTSO as any problem or 
event which in the opinion of the local researcher was 
unanticipated, reflects new and increased risk to the subjects, and 
was possibly related to the research procedures. 
 
 
Problems/events that are unanticipated and involve new or 
increased risk to subjects should be reported only if in the opinion 
of the local researcher they are possibly, probably or definitely 
related to the research procedures. 
10.2 
Reporting Requirements 
 
 
10.3 
Additional Events Requiring Reporting To the IRB  
In addition the following events/problems meet the IRB’s definition 
of UPIRTSO and should be reported to the IRB (but not the DSMC) 
within the 10 working day time frame: 
 Any event (including on-site and off-site adverse 
events, injuries, side effects, deaths or other 
problems) which in the opinion of the local 
investigator was unanticipated, involved new or 
increased risk to subjects or others, and was possibly 
related to the research procedures; 
Agency 
Criteria for 
reporting 
Timeframe 
Form to Use 
Submit to: 
Copy AE to: 
U of MN IRB 
Pose new or 
increased risk, 
unexpected, at 
least possibly 
related 
10 Working 
Days 
UPIRTSO form found on the 
IRB’s Web site at 
http://www.research.umn.edu/i
rb/download/ . 
MMC 820 
Study file 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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 Any accidental or unintentional change to the IRB-
approved protocol that increases risk or has the 
potential to recur; 
 Any deviation from the protocol taken without prior 
IRB review to eliminate apparent immediate hazard to 
a research subject; 
 Any publication in the literature, safety monitoring 
report (including Data and Safety Monitoring Reports), 
interim result or other finding that indicates an 
unexpected change to the risk/benefit ratio of the 
research; 
 Any breach in confidentiality that may involve risk to 
the subject or others; 
 Any complaint of a subject that cannot be resolved by 
the research staff; or 
 Any other possibly related event which in the opinion 
of the investigator constitutes an unanticipated risk. 
 
10.4 
Events Not Requiring Reporting Until Time Of Annual Review   
Those unanticipated problems/events that reflect new or increased 
risk to the subjects that the local investigator deems unlikely or not 
related to the research procedure DO NOT meet the IRB’s 
definition of UPIRTSO and should be reported in summary form 
(using a table or spreadsheet) only at the time of IRB continuing 
review.  Accompanying documentation (sponsor report forms, etc.) 
should NOT be included with this summary.  If received, such 
accompanying documentation will be returned to the investigator.  
10.5 
Reporting of SAEs to Forest Research Institute (FRI)  
 
Serious Adverse Event (SAE) 
A serious adverse event is one that: 
 Results in death 
 Is an immediate threat to life 
 Requires inpatient hospitalization, or prolongation of existing 
hospitalization 
 Results in persistent or significant disability/incapacity 
 Is a congenital anomaly or birth defect. 
 
Causality Assessment 
For all AEs, the Investigator must provide an assessment of causal 
relationship to the IP. Causal relationship must be assessed by 
answering the following question: 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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Is there a reasonable possibility the IP caused the event? 
 
Yes: There is a possible or probable relationship (ie, there 
is a reasonable or strong temporal relationship, and 
the events are unlikely to be attributable to other 
drugs, underlying diseases, or other factors). 
Dechallenge and/or rechallenge (if available) is 
positive. 
 
No: 
The relationship is unlikely or nonexistent (ie, there is 
no strong temporal relationship and/or the use of 
other drugs, underlying diseases, or other factors 
provide plausible explanations for the event), or the 
patient did not take the IP. 
 
The Sponsor (Principal Investigator) is required to inform Forest 
Global Drug Safety of all SAEs. Forest Global Drug Safety must be 
notified immediately regarding any SAE that occurs after informed 
consent is obtained. 
The Principal Investigator must report the event within 24 hours of 
first knowledge of any AE that meets one of the criteria for an SAE, 
to Forest Global Drug Safety on an SAE report form. If, during 
follow-up, any nonserious AE worsens and eventually meets the 
criteria for an SAE, that AE should be recorded as a new SAE. 
The study center must transmit the SAE report form to the SAE fax 
number (631) 858-7906) within 24 hours of first awareness of the 
event at the study center. 
Supplemental information shall be submitted as soon as available 
and may include laboratory results, radiology reports, progress 
notes, hospital admission and emergency room notes, holding and 
observation notes, discharge summaries, autopsy reports, and 
death certificates. 
Reporting of Pregnancy to Forest Research Institute 
Study center personnel must report every pregnancy on a 
pregnancy report form as soon as possible (within 24 hours of first 
awareness of the pregnancy to the pregnancy fax number, (631) 
858-7906), even if no AE has occurred, and follow it to term. If, 
however, the pregnancy is associated with an SAE (eg, if the 
mother is hospitalized for dehydration), in addition to the pregnancy 
report form, a separate SAE report form must be filed.  

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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Fax all relevant SAE or pregnancy information to Forest Global 
Drug Safety. Contact information for Forest Global Drug Safety, 
personnel is as follows: 
FOREST GLOBAL DRUG SAFETY DEPARTMENT  
Fax: (631) 858-7906 
 
11. 
DATA AND SAFETY MONITORING PLAN 
Weekly meetings of the study's principal investigator and staff will be held 
to discuss matters related to the safety of protocol participants, validity 
and integrity of the data, enrollment rate, retention of participants, 
adherence to protocol, and data completeness. 
 
12. 
STATISTICAL CONSIDERATIONS 
This is a randomized, double-blinded, placebo-controlled Phase II study to 
obtain a preliminary estimate of the effects of nebivolol compared to 
atenolol and placebo on endothelial function (measured by arterial 
elasticity) and cardiovascular disease risk (measured by RDS).  
 
12.1  Statistical Methodology 
The primary analysis of the study is descriptive, to obtain a point 
estimate and 95% confidence interval of the difference in small 
artery elasticity (C2) between nebivolol and atenolol treatment arms 
and nebivolol and placebo at the end of the observation period (9 
months). Point estimates and 95% confidence intervals for the 
improvement in C2 within each treatment will also be presented. 
 
Secondary analysis estimating difference in Rasmussen Disease 
Score (RDS) improvement between the nebivolol and atenolol 
treatment groups along with nebivolol and placebo groups at the 
end of the observation period (9 months) will also be completed.  
 
Other secondary analyses include estimates of the associations 
among changes in RDS as well as risk factor and biomarker 
measurements from baseline to the 3, and 9 month time points in 
the two positive comparator groups. 
 
Unpaired t-tests will be used to compare the means of C2 (small 
artery elasticity) as well as all RDS test component and biomarker 
values for each subject group at each time point.  Paired t-tests will 
be used to compare baseline values and values from subsequent 
time points within one group.  A P-value of < 0.05 will be 
considered statistically significant. 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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Comparison of sensitivity and variability for C2 and flow-mediated 
dilation (FMD) methodologies used in quantifying endothelial 
function of each group over the 9 month study period will also be 
included in the secondary analyses.  Data will be analyzed within 
and between test groups with a significance level of P ≤ 0.05. 
 
12.2  Design and Sample Size Justifications 
A sample size of 25 subjects per arm will be adequate to detect a 
difference in small artery elasticity of 3.3 units (ml/mm Hg x 100) 
between positive comparators when power = 0.9 and α= 0.05.  This 
is assuming a standard deviation of ± 3.57 units.  This assumption 
is made based on a previous clinical trial measuring small artery 
elasticity in patients undergoing anti-hypertensive therapy [14].  
 
Subjects in the previous study were not selected on the basis of C2 
as they are in EVIDENCE.  Therefore, it is reasonable to assume 
that our actual standard deviation will be much smaller than our 
estimate giving us a conservative population sample of 75.  
Assuming a smaller deviation of 3.0 (instead of 3.57) we would still 
have an adequate sample with a dropout rate of 7.6%.  If rates of 
attrition exceed 7.6%, subjects will be replaced 
 
 
13. 
ADMINISTRATIVE REQUIREMENTS 
13.1 Good Clinical Practice 
The study will be conducted in accordance with the International 
Conference on Harmonization (ICH) for Good Clinical Practice 
(GCP) and the appropriate regulatory requirement(s).  The 
investigator will be thoroughly familiar with the appropriate use of 
the drug as described in the protocol.  Essential clinical documents 
will be maintained to demonstrate the validity of the study and the 
integrity of the data collected.  Master files should be established at 
the beginning of the study, maintained for the duration of the study 
and retained according to the appropriate regulations.   
13.2 Ethical Considerations 
The study will be conducted in accordance with ethical principles 
founded in the Declaration of Helsinki.  The IRB will review all 
appropriate study documentation in order to safeguard the rights, 
safety and well-being of the patients.  The protocol, informed 
consent, written information given to the patients, other recruitment 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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materials and any revisions to these documents will be provided to 
the IRB by the investigator.   
13.3 Monitoring and Auditing 
This study will be monitored according to FDA/GCP guidelines.   
 
The investigator will permit study-related monitoring, audits, and 
inspections by the IRB, government regulatory bodies, and 
University compliance and quality assurance groups of all study 
related documents (e.g. source documents, regulatory documents, 
data collection instruments, study data etc.).  The investigator will 
ensure the capability for inspections of applicable study-related 
facilities (e.g. pharmacy, diagnostic laboratory, etc.). 
 
Participation as an investigator in this study implies acceptance of 
potential inspection by government regulatory authorities and 
applicable University compliance and quality assurance offices. 
 
13.4 Record Retention 
The investigator will retain study records, including source data, 
copies of case report form, and all study correspondence in a 
secured facility for at least 2 years after the last study related 
publication.   
 
 
14. 
REFERENCES 
 
 
1. 
Dawes, M., et al., The vasodilator action of nebivolol in forearm vasculature of 
subjects with essential hypertension. Br J Clin Pharmacol, 1999. 48(3): p. 460-3. 
2. 
Maffei, A. and G. Lembo, Nitric oxide mechanisms of nebivolol. Ther Adv 
Cardiovasc Dis, 2009. 3(4): p. 317-27. 
3. 
Lund-Johansen, P., Relationship between cardiovascular haemodynamics and 
goals of antihypertensive therapy. J Hum Hypertens, 1993. 7 Suppl 1: p. S21-8. 
4. 
Munzel, T. and T. Gori, Nebivolol: the somewhat-different beta-adrenergic 
receptor blocker. J Am Coll Cardiol, 2009. 54(16): p. 1491-9. 
5. 
Ignarro, L.J., Experimental evidences of nitric oxide-dependent vasodilatory 
activity of nebivolol, a third-generation beta-blocker. Blood Press Suppl, 2004. 1: 
p. 2-16. 
6. 
Lekakis, J.P., et al., Effect of nebivolol and atenolol on brachial artery flow-
mediated vasodilation in patients with coronary artery disease. Cardiovasc Drugs 
Ther, 2005. 19(4): p. 277-81. 

EVIDENCE Study                                                                                                                        PI: JN COHN 
 
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7. 
Tzemos, N., P.O. Lim, and T.M. MacDonald, Nebivolol reverses endothelial 
dysfunction in essential hypertension: a randomized, double-blind, crossover 
study. Circulation, 2001. 104(5): p. 511-4. 
8. 
Cohn, J.N., et al., Screening for early detection of cardiovascular disease in 
asymptomatic individuals. Am Heart J, 2003. 146(4): p. 679-85. 
9. 
Florea, N., et al., Detecting Abnormalities of Arterial and Cardiac Function and 
Structure Rather than Using Risk Factors to Identify the Likelihood for Future 
Cardiovascular Morbid Events. In Review. 
10. 
Gilani, M., et al., Role of nitric oxide deficiency and its detection as a risk factor 
in pre-hypertension. Journal of the American Society of Hypertension, 2007. 1(1): 
p. 44-55. 
11. 
Peralta, C., et al., Structural and Functional Vascular Alterations and Incident 
Hypertension in Normotensive Adults. American Journal of Epidemiology, 2009. 
12. 
Grey, E., et al., Reduced small artery but not large artery elasticity is an 
independent risk marker for cardiovascular events. Am J Hypertens, 2003. 16(4): 
p. 265-9. 
13. 
Cohn, J.N., et al., Coadministered amlodipine and atorvastatin produces early 
improvements in arterial wall compliance in hypertensive patients with 
dyslipidemia. Am J Hypertens, 2009. 22(2): p. 137-44. 
14. 
Duprez, D.A., et al., Beneficial effects of valsartan in asymptomatic individuals 
with vascular or cardiac abnormalities: the DETECTIV Pilot Study. J Am Coll 
Cardiol, 2007. 50(9): p. 835-9. 
15. 
Yeboah, J., et al., Predictive value of brachial flow-mediated dilation for incident 
cardiovascular events in a population-based study: the multi-ethnic study of 
atherosclerosis. Circulation, 2009. 120(6): p. 502-9. 
16. 
Rosei, E.A. and M.L. Muiesan, Early target organ damage and its reversibility: 
the heart. Clin Exp Hypertens, 2004. 26(7-8): p. 673-87.