Improving Treatment Personalization of Pulmonary Hypertension Associated With Diastolic Heart Failure
Phase: PHASE4
Conditions: Pulmonary Hypertension, Diastolic Heart Failure, Heart Failure With Preserved Ejection Fraction
Sponsor: University of Florida

Personalized Treatment of PH with DD Protocol, Version 3, 10/08/18 
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PROTOCOL 
 
Title: Improving treatment personalization of pulmonary hypertension associated with diastolic heart 
failure 
 
Protocol Version: 3 
10/08/2018 
 
Investigators: 
  
Julio Duarte, PharmD, PhD, Assistant Professor 
Department of Pharmacotherapy and Translational Research, UF 
 
Hassan Alnuaimat, MD, Associate Professor 
Division of Pulmonary, Critical Care and Sleep Medicine, UF 
 
Ali Ataya, MD, Assistant Professor 
Division of Pulmonary, Critical Care and Sleep Medicine, UF 
 
 
 

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Study Hypothesis and Specific Aims  
The objective of this application is to evaluate nebivolol as a potential treatment for patients with 
pulmonary hypertension (PH) associated with diastolic heart failure, or heart failure with preserved 
ejection fraction (HFpEF).  Our central hypothesis is that nebivolol improves PH severity in patients 
with HFpEF, as measured by hemodynamic and clinical parameters.  The rationale for this research is 
that once we determine the extent to which nebivolol improves PH, it could be developed as a treatment 
for PH and HFpEF, especially if patients who respond best can be identified before treatment.  
We will test our central hypothesis and accomplish these objectives by pursuing the following 
specific aim:  
 
Define the clinical role of nebivolol as a potential treatment for PH associated with HFpEF using 
hemodynamic and functional status measurements. 
Our working hypothesis is that nebivolol, via its β1-antagontistic and β3-agonistic activities, as well as its 
anti-inflammatory, anti-proliferative, and endothelial NO-stimulating properties, will decrease 
pulmonary pressures and improve 6-minute walk distance and dyspnea scores in patients with HFpEF-
associated PH. 
 
Background and Significance 
Clinically, PH is marked by increased pulmonary vascular resistance leading to right heart 
failure, and ultimately death.1  Thus, PH carries a poor prognosis, with a yearly mortality rate of 9%.2  
PH can include either pulmonary arterial hypertension (PAH) or pulmonary venous hypertension (PVH), 
which is often caused by left-sided heart failure.  Increased pulmonary artery pressure (PAP) in patients 
with PVH develops from backward transmission of increased left atrial pressure, and is the most 
common cause of PH, with studies estimating its presence in 60-90% of heart failure patients.3-6  
However, approximately half of these patients have PAPs that are disproportionally higher than 
expected from their left arterial pressure, with greatly increased peripheral vascular resistance.4  This 
increase in PAP is associated with significantly worse outcomes, with one study estimating that heart 
failure patients with very high PAP possess an increased the risk of death by greater than 2-fold 
compared to heart failure patients with normal PAP.7  Such poor outcomes are particularly troubling in 
patients with PH and HFpEF, where no established guidelines for treatment exist.8  Thus, development 
of treatments for this category of PH is greatly needed. 
Current approved treatment classes for PAH, such as endothelin receptor antagonists and 
prostacyclins have either been shown ineffective, or have been associated with increased mortality when 
used in heart failure patients.9,10  Nebivolol is a third generation β-blocker which has been shown to 
improve diastolic dysfunction in both rats and humans with HFpEF.11-13  In addition, this particular β-
blocker has a profile that should make it ideal for treatment HFpEF patients with PH.  Importantly, 
nebivolol has been shown in a clinical study to improve mean PAP and PCWP in HFpEF patients 
without PH.13  However, to what extent it improves these hemodynamic parameters in HFpEF patients, 
who also have PH, is unknown. 
This project will contribute toward determining whether these potentially beneficial properties of 
nebivolol, known to improve diastolic dysfunction, will also improve PH severity in patients with 
HFpEF. This contribution will be important because it could uncover a potential treatment for a disease 
category that currently has no accepted treatments.  If nebivolol significantly improves PH severity in 
patients with HFpEF, it can be further researched as a probable treatment.  Furthermore, this project 
should also advance knowledge of the hemodynamic effects of chronic nebivolol treatment in HFpEF 
patients, as very few clinical studies have measured hemodynamics by right heart catheterization both 
before and after chronic oral treatment.  
 
 

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Methods 
This project will be a prospective, open-label four-month clinical pilot study of 40 patients with 
PH and HFpEF.  Patients will be started at 2.5 mg of nebivolol by mouth daily if they were not taking a 
beta-blocker at enrollment, and titrated up to 10 mg daily, as tolerated.  Patients who cannot tolerate a 
dose increase will continue on the maximum tolerated dose throughout the study.  Patients already on a 
beta-blocker at enrollment will begin on 5 mg and will be titrated to 10 mg daily. DNA and RNA will be 
collected for genomic studies of disease and drug response.  All study procedures will occur at either the 
UF Clinical Research Center (CRC) or Shands Hospital. 
 
 
 
Visit 1 (week 0):  
• Blood sample: 2x 8 mL PAXgene (RNA), 1x 10mL lavender top (plasma and PBMCs), 1x 3mL 
lavender top (CBC with diff), 2x 4mL Li Heparin (nt-proBNP, CMP), 1x2.7mL blue top (INR) 
• Vital signs: blood pressure, pulse, respirations, height, weight, etc. 
• Dyspnea index 
• 6-minute walk test 
• Medication history 
• EKG 
Table 1. Procedures for each interaction with subjects 
Test/Procedure 
Visit 1/1A  
(wk 0-1) 
Call 1 
(wk 1) 
Call 2 
(wk 2) 
Visit 2 
(wk 4) 
Call 3 
(wk 5) 
Visit 3 
(wk 8) 
Call 4 
(wk 9) 
Visit 4 
(wk 18) 
right heart 
catheterization 
X* 
 
 
 
 
 
 
X 
transthoracic echo 
X* 
 
 
 
 
 
 
X 
electrocardiogram 
X 
 
 
X 
 
X 
 
X 
6-minute walk 
distance 
X 
 
 
X 
 
X 
 
X 
vital signs 
X 
 
 
X 
 
X 
 
X 
dyspnea index 
X 
 
 
X 
 
X 
 
X 
complete blood 
count 
X 
 
 
X 
 
X 
 
X 
INR 
X 
 
 
 
 
X 
 
X 
liver function test 
X 
 
 
X 
 
X 
 
X 
basic metabolic 
panel 
X 
 
 
X 
 
X 
 
X 
nt-proBNP 
X 
 
 
 
 
X 
 
X 
RNA collection 
X 
 
 
X 
 
X 
 
X 
DNA collection 
 
 
 
X 
 
X 
 
 
serum collection 
X 
 
 
X 
 
X 
 
X 
change in 
nebivolol dose 
X 
 
X 
X 
 
 
 
X 
adverse effect 
assessment 
 
X 
X 
 
X 
 
X 
 
medication history 
X 
 
 
X 
 
X 
 
X 
* = if not done within previous 3 months as part of clinical care 

Personalized Treatment of PH with DD Protocol, Version 3, 10/08/18 
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• Patients will be asked to take oral nebivolol 2.5 mg (or 5 mg) once daily until Visit 2 (if visit 1A 
is not needed).  Instruct patient to discontinue previous beta-blocker and begin nebivolol today 
if they have not taken any beta-blocker today, and tomorrow if they have already taken a beta-
blocker today. 
• Place note in medical record documenting name of study, responsible physician, procedures, and 
medication dose. 
• If possible, schedule Visit 1A or Visit 2. 
• Once complete, provide patient with compensation ($50). 
Visit 1A – IF NEEDED (week 0-1): 
• If the patient has not received a two-dimensional transthoracic echocardiogram (TTE) within 3 
months of enrollment, it will be done for research purposes, possibly on the same day as visit 1.   
• If the patient has not received a right heart catheterization (RHC) within 3 months of enrollment, 
it will be done for research purposes (Appendix 1). 
• Patients will be asked to take oral nebivolol 2.5 mg (or 5 mg) once daily until Visit 2. Instruct 
patient to discontinue previous beta-blocker and begin nebivolol today if they have not taken any 
beta-blocker today, and tomorrow if they have already taken a beta-blocker today. 
• Once complete, provide patient with compensation ($200). 
Phone Call 1 (week 1): 
• How does patient feel compared to before starting study drug?   
• Any perceived side effects? 
• If not done already, schedule Phone Call 2 
Phone Call 2 – IF NEEDED (week 2): 
• How does patient feel compared to before starting study drug?   
• Any perceived side effects? 
• If tolerated, increase nebivolol dose to 5 mg (after approval by study physician) 
• If not done already, schedule Visit 2. 
Visit 2 (week 4): 
• Blood sample: 1x 6 mL purple top (DNA), 1x 8 mL PAXgene (RNA), 1x 10mL lavender top 
(plasma and PBMCs), 1x 3mL lavender top (CBC with diff), 1x 4mL Li Heparin (CMP) 
• Vital signs: blood pressure, pulse, respirations, height, weight, etc. 
• Dyspnea index 
• 6-minute walk test 
• Medication history 
• EKG 
• If tolerated, increase nebivolol dose to 10 mg once daily. 
• Update medical record to reflect new dose. 
• If possible, schedule Visit 3. 
• Once complete, provide patient with compensation ($40). 
Phone Call 3 (week 5): 
• How does patient feel compared to before starting study drug?   
• Any perceived side effects? 
• Provide results of safety assessment (everything looks similar to baseline OR significant 
difference in ________; the study physician recommends you _________.) 

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• If not done already, schedule Visit 3. 
Visit 3 (week 8): 
• Blood sample: 1x 6 mL purple top (DNA), 1x 8 mL PAXgene (RNA), 1x 10mL lavender top 
(plasma and PBMCs), 1x 3mL lavender top (CBC with diff), 2x 4mL Li Heparin (nt-proBNP, 
CMP), 1x2.7mL blue top (INR) 
• Vital signs: blood pressure, pulse, respirations, height, weight, etc. 
• Dyspnea index 
• Medication history 
• 6-minute walk test 
• EKG 
• If possible, schedule Visit 4. 
• Once complete, provide patient with compensation ($40). 
Phone Call 4 (week 9): 
• How does patient feel compared to before starting study drug?   
• Any perceived side effects? 
• Provide results of safety assessment (everything looks similar to baseline OR significant 
difference in ________; the study physician recommends you _________.) 
• If not done already, schedule Visit 4. 
Visit 4 (week 18):  
• Blood sample: 2x 8 mL PAXgene (RNA), 1x 10mL lavender top (plasma and PBMCs), 1x 3mL 
lavender top (CBC with diff), 2x 4mL Li Heparin (nt-proBNP, CMP), 1x2.7mL blue top (INR) 
• Vital signs: blood pressure, pulse, respirations, height, weight, etc. 
• Dyspnea index 
• Medication history 
• 6-minute walk test 
• EKG 
• Two-dimensional transthoracic echocardiogram (TTE) for research purposes 
• RHC for research purposes (Appendix 1).   
• Based on study physician recommendation, patients will be advised on how to proceed with 
beta-blocker treatment after the end of the study. 
• Update medical records to indicate patient has completed study.   
• Once complete, provide patient with final compensation ($250). 
 
Eligibility Criteria 
Study Population. This study will include PH patients from Shands Hospital and UF Health 
pulmonary hypertension and cardiology clinics.  Patients must be diagnosed with PH by right heart 
catheterization (RHC).  This procedure is the gold-standard for PH diagnosis and is the most accurate 
way to measure the hemodynamics necessary to differentiate subtypes of PH.  Inclusion criteria for this 
study include:  
1. Adults (≥ 18 years of age) with World Health Organization Group 2 Pulmonary Hypertension:  
a. Mean pulmonary artery pressure (mPAP) ≥ 25 mmHg,  
b. And pulmonary capillary wedge pressure (PCWP) ≥ 15 mmHg or left ventricular end 
diastolic pressure (LVEDP) ≥ 15 mmHg 

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2. Evidence of either diastolic dysfunction on echocardiogram OR elevated filling pressures on 
invasive hemodynamic testing OR BNP>200 (NT-proBNP>220) pg/mL  
3. NYHA class II-IV symptoms  
4. Left ventricular ejection fraction (LVEF) ≥ 45% 
To assure any effect on hemodynamics are not due to other medications, patients must have no 
changes within one month to their cardiovascular medication regimen, including ACE-inhibitors, 
angiotensin receptor blockers, diuretics, and nitrates.  Exclusion criteria include:  
1. Other causes of heart failure other than diastolic dysfunction, such as restrictive cardiomyopathy 
or infiltrative cardiomyopathy 
2. Women who are pregnant or nursing 
3. Liver cirrhosis,  
4. primary valvular disease 
5. Acute coronary syndrome 
6. Causes of PH other than that of heart failure, such as: chronic thromboembolic PH, sickle-cell 
disease, or sarcoidosis 
7. Severe bradycardia or greater than 1st degree heart block 
8. Decompensated heart failure 
9. Current use of a third generation beta-blocker (nebivolol, carvedilol, or labetalol) or high dose of 
other beta-blockers (greater than 100 mg daily of metoprolol, or equivalent).  
 
Plans for subject selection, recruitment, and documentation of informed consent 
This study will include PH patients from Shands Hospital and UF Health pulmonary 
hypertension and cardiology clinics.  Eligibility will be reviewed and if requirements are met, patients 
will be approached to gauge interest.  If interested, patients will be asked to provide informed written 
consent. 
 
Description of Procedures 
 
Hemodynamic Measurements.  To confirm the diagnosis of PH associated with HFpEF and 
obtain baseline hemodynamic measurements, right heart catheterizations (RHCs) will be performed by 
UF cardiologists and pulmonologists using standard techniques. Any procedures done during 
catheterization beyond those mentioned will be at the discretion of the physician performing the for 
clinical indications.  
Transthoracic echocardiograms (TTEs) performed by UF Health technicians will also be used to 
obtain further hemodynamic parameters, including those that are indicative of diastolic dysfunction.  
TTEs will be read by a cardiologist as per American Society of Echocardiography guidelines.  Diastolic 
dysfunction will be determined by tissue Doppler imaging.  RV measurements including size, lateral 
tricuspid annular velocity, E wave, A wave, and isovolumic relaxation time will be performed. 
 
Functional Assessments. The 6-minute walk test will be performed in accordance with standard 
practice both at baseline and at completion of the study.  Briefly, subjects will be asked to walk for six 
minutes along a pre-measured path, with a practice walk being performed first.  Distance walked, 
oxygen saturation, and a Dyspnea Index will be determined. 
 
Statistical Methods 
Planned statistical analysis: Student’s t-test for paired samples will be used to determine 
differences between hemodynamic measurements taken before and after six months of nebivolol 

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treatment. Thus, each patient will serve as their own control. The two primary efficacy phenotypes to be 
measured are mPAP and PCWP.  In secondary analyses, mitral valve Doppler flow velocity pattern, CO, 
PVR, CI and TPR will also be analyzed in an attempt to better characterize the mechanisms by which 
nebivolol affects the hemodynamic profile.  In addition, Student’s t-test for paired samples will be used 
to determine differences in 6-minute walk time before and after nebivolol treatment.  Fisher’s Exact Test 
will be used to compare dyspnea scores before and after six months of nebivolol treatment.  In all 
analyses, P ≤ 0.05 in a two-tailed distribution will be considered statistically significant. Statistical 
analyses will be performed using SAS 9.2 (SAS Institute, Cary, NC). 
 
Rationale for selection of subject 
Sample Size Calculation. Change in mean pulmonary artery pressure was used to estimate the 
sample size required to achieve satisfactory statistical power for this study. We calculated our sample 
size to be well-powered to detect a 15% decrease in mean mPAP (a clinically significant change).  This 
would be approximately 4 mmHg at our minimum mPAP cut-off of 25 mmHg.  We assumed a standard 
deviation of 5.5 derived from previous HFpEF treatment studies.13  Thus, with a power of 0.95, and a 
two-sided α of 0.05, we would require a sample size of 27 patients.  Because of the length of the study, 
we estimate an additional 30% will be needed to offset study attrition, thus a total sample size up to 40 
patients will be enrolled. 
 
Safety Monitoring and Assessment  
Patients will be called 1 week after each dose change.  BP and HR will be measured at each visit, 
as well as BMP, ECG, and LFT will be performed as safety assessments.  Accumulated safety data will 
be reviewed by a study physician every six months to assess overall safety of nebivolol treatment. 
 
Data Management  
Patient data will be initially recorded using the patient data collection form and RHC data 
collection form. Patient data will then be transferred and stored using a custom-built REDCap database.  
REDCap is a secure, web-based application for building and managing online databases for the 
collection and entry of research data.  Consents and other paper documentation will be kept in a locked 
cabinet in Dr. Duarte’s locked, private office. 
 
Risks and Benefits 
Patients may not directly benefit.  There is a potential benefit from improvements in progression 
of their PH.  The potential risks include: 
• Nebivolol:  Risk of side effects such as: large decrease in blood pressure (less likely), headache 
(less likely), dizziness (less likely), nausea (rare), fatigue (rare), diarrhea (rare), difficulty 
breathing (very rare), and slow heart rate (very rare).   
• Blood draws: discomfort at needle site (less likely), bruising at needle site (less likely), pain at 
site (less likely), swelling of vein (rare), fainting (rare), and infection (rare). 
• Echocardiogram: no risks associated with this procedure 
• Right heart catheterization: pain (less likely) or infection at catheterization sight (rare), 
vascular/valve damage (very rare), edema (rare), bruising (less likely), internal bleeding (very 
rare), blood clots (very rare), excessive fluid around the heart (very rare), and irregular heart 
rhythms (very rare). 
• 6-minute walk distance: fatigue during walk (less likely) 
• Accidental disclosure of PHI (rare) 
 

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Relevant Literature 
 
1. 
D'Alonzo GE, Barst RJ, Ayres SM, et al. Survival in patients with primary pulmonary hypertension. Results 
from a national prospective registry. Annals of internal medicine. Sep 1 1991;115(5):343-349. 
2. 
Benza RL, Miller DP, Gomberg-Maitland M, et al. Predicting survival in pulmonary arterial hypertension: 
insights from the Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease 
Management (REVEAL). Circulation. Jul 13 2010;122(2):164-172. 
3. 
Lam CS, Roger VL, Rodeheffer RJ, Borlaug BA, Enders FT, Redfield MM. Pulmonary hypertension in heart 
failure with preserved ejection fraction: a community-based study. Journal of the American College of 
Cardiology. Mar 31 2009;53(13):1119-1126. 
4. 
Schwartzenberg S, Redfield MM, From AM, Sorajja P, Nishimura RA, Borlaug BA. Effects of vasodilation 
in heart failure with preserved or reduced ejection fraction implications of distinct pathophysiologies on 
response to therapy. Journal of the American College of Cardiology. Jan 31 2012;59(5):442-451. 
5. 
Ghio S, Gavazzi A, Campana C, et al. Independent and additive prognostic value of right ventricular 
systolic function and pulmonary artery pressure in patients with chronic heart failure. Journal of the 
American College of Cardiology. Jan 2001;37(1):183-188. 
6. 
Willens HJ, Kessler KM. Severe pulmonary hypertension associated with diastolic left ventricular 
dysfunction. Chest. Jun 1993;103(6):1877-1883. 
7. 
Bursi F, McNallan SM, Redfield MM, et al. Pulmonary pressures and death in heart failure: a community 
study. Journal of the American College of Cardiology. Jan 17 2012;59(3):222-231. 
8. 
McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary 
hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus 
Documents and the American Heart Association developed in collaboration with the American College of 
Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association. Journal 
of the American College of Cardiology. Apr 28 2009;53(17):1573-1619. 
9. 
Califf RM, Adams KF, McKenna WJ, et al. A randomized controlled trial of epoprostenol therapy for 
severe congestive heart failure: The Flolan International Randomized Survival Trial (FIRST). American 
heart journal. Jul 1997;134(1):44-54. 
10. 
Packer M, McMurray J, Massie BM, et al. Clinical effects of endothelin receptor antagonism with 
bosentan in patients with severe chronic heart failure: results of a pilot study. Journal of cardiac failure. 
Feb 2005;11(1):12-20. 
11. 
Zhou X, Ma L, Habibi J, et al. Nebivolol improves diastolic dysfunction and myocardial remodeling 
through reductions in oxidative stress in the Zucker obese rat. Hypertension. Apr 2010;55(4):880-888. 
12. 
Ma L, Gul R, Habibi J, et al. Nebivolol improves diastolic dysfunction and myocardial remodeling through 
reductions in oxidative stress in the transgenic (mRen2) rat. American journal of physiology. Heart and 
circulatory physiology. Jun 1 2012;302(11):H2341-2351. 
13. 
Nodari S, Metra M, Dei Cas L. Beta-blocker treatment of patients with diastolic heart failure and arterial 
hypertension. A prospective, randomized, comparison of the long-term effects of atenolol vs. nebivolol. 
European journal of heart failure. Oct 2003;5(5):621-627.