Mineralocorticoid Receptor Antagonism for Cardiovascular Health in HIV--The MIRACLE HIV Study
Phase: NA
Conditions: HIV
Sponsor: Massachusetts General Hospital

MIneralocorticoid Receptor Antagonism for CardiovascuLar hEalth in HIV 
The MIRACLE HIV Study 
 
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I.  Background and Significance 
Cardiovascular related complications are a leading cause of morbidity and 
mortality in well-treated HIV patients in whom we have shown increased activation 
of the renin-angiotensin–aldosterone system (RAAS). The availability of newer 
antiretroviral therapies (ART) with improved efficacy, safety and tolerance has allowed 
HIV patients to achieve good virologic16 control and reduce the burden of AIDS defining 
illnesses. In this regard, HIV patients are living longer and the focus of their healthcare is 
now driven by chronic co-morbidities. Among these co-morbidities, large cohort studies 
of the well-treated HIV population have revealed that cardiovascular disease (CVD) 
accounts for approximately 10% of all deaths1,2 and CVD is 1.5-2 fold higher in the HIV 
population compared to a matched non-HIV population.3,4 This proposal will provide 
evidence supporting mineralocorticoid receptor (MR) blockade as a novel strategy for 
CVD risk reduction in HIV. We present significant data demonstrating for the first time 
impaired physiological regulation of RAAS leading to excess RAAS activation among 
HIV patients. We demonstrate significant increases in aldosterone linked to metabolic 
abnormalities, including visceral fat accumulation, insulin resistance and inflammation in 
HIV and further hypothesize that RAAS activation has critical effects on CVD in HIV.  
 
Unique RAAS physiology may modulate increased burden of CVD in HIV. The 
RAAS is an important hormone system, which classically regulates blood volume and 
sodium balance through MR activation in epithelial tissues. Compelling data from animal 
and human studies suggest that RAAS activity may also contribute to the development 
of vascular and myocardial injury, largely through stimulatory effects on inflammation 
and fibrosis. These data and new observations by our group on the effect of blocking 
RAAS activation suggest a compelling management strategy aimed at reducing CV 
related morbidity and mortality in this at-risk HIV population, for whom comprehensive 
strategies to reduce CVD are lacking. 
 
HIV patients have increased risk of vascular inflammation and subclinical 
atherosclerosis, which may be addressed by MR blockade. Using aortic FDG-PET, 
we have shown direct evidence of increased arterial inflammation among HIV patients.5 
While studies show that HIV patients have impaired endothelial dependent vasodilation 
vs. non-HIV patients,6 functional assessment of this inflamed coronary vasculature in 
HIV is lacking. Moreover, ART treated HIV patients have persistent elevations in ICAM 
and VCAM,7,8 markers of vascular inflammation which correlate with the extent of 
atherosclerosis in the non-HIV population.9 Using coronary CTA, we have shown 
increased subclinical atherosclerosis in HIV and demonstrated the plaque most often to 
be noncalcified with high risk features, including positive remodeling and low 
attenuation—plaque characteristics more vulnerable to rupture.10 Indeed, noncalcified 
plaque is distinct from long-standing, hardened calcified plaque, which is more often 
associated with traditional CV risk factors than noncalcified plaque. In this regard, we 
have established a significant link between noncalcified plaque and specific markers of 
inflammation and immune activation, soluble CD163 and CD14 and Lp-PLA2, in HIV as 
opposed to traditional risk factors.11-13 Moreover, progression of carotid intima-media 
thickness over 24 months was associated with increased baseline urinary aldosterone 
excretion (preliminary data r=0.67, P=0.049) in HIV. Taken together, these data suggest 
inflamed coronary vasculature and high risk plaque in HIV, in whom our preliminary data 
suggest a potential linkage of inflammation and atherosclerosis to RAAS activation. In 
this proposal, we will test the hypothesis that Mblockade addresses these unique 

MIneralocorticoid Receptor Antagonism for CardiovascuLar hEalth in HIV 
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features of CVD in HIV.  
 
Coronary flow reserve (CFR) is a physiologic marker of vascular function of the 
coronary bed, which is reduced in HIV. CFR, the ratio of maximally stimulated to rest 
coronary blood flow (CBF), is well-validated to characterize coronary vasculature 
function.14-16 Both large vessel coronary lesions (i.e. coronary artery disease [CAD]) and 
microvascular dysfunction may lead to impaired CFR. Our group and others 
demonstrated that impaired CFR predicts cardiovascular morbidity and mortality in non-
HIV populations. Specifically, we found impaired CFR (median 1.9) to be associated with 
a 4.9-fold increase in CV mortality among non-HIV patients.17 Furthermore, CV mortality 
is increased among non-HIV patients with impaired vs. normal flow reserve (4.2 vs. 
0.4%/yr).17 In addition, 59% of patients with non-obstructive CAD have a reduced CFR 
<1.93 on cardiac PET,15 and impaired CFR predicts cardiac mortality independent of 
obstructive disease.16,18 While CFR may be a useful physiologic biomarker for CVD, few 
studies have examined CFR in HIV. A short 5 week study reported reduced CFR in HIV 
patients after initiation of ART.19 In this proposal, we present new preliminary data 
demonstrating greater impairment of CFR in HIV compared to non-HIV 
subjects20(1.74±0.73 vs. 3.88±0.70) assessed by cardiac PET, the gold standard for 
evaluation of CFR. These data highlight CFR as a diagnostic tool to uniquely capture 
those asymptomatic patients of intermediate CVD risk with potential limitations to flow 
reserve of the coronary microvasculature, which may contribute to ischemia, a clinical 
scenario relevant to HIV patients with increased subclinical plaque progression. 
Importantly, we show that MR blockade improves CFR, suggesting it may be a useful 
strategy to improve vascular dysfunction in HIV. Reduced stress myocardial blood flow 
on cardiac MRI may be another marker of reduced myocardial perfusion and has been 
independently associated with major adverse cardiovascular events among those 
without known CVD.  
 
In addition to reduced CFR, HIV patients demonstrate myocardial fibrosis and 
diastolic dysfunction which may also uniquely contribute to CVD in HIV. 
Myocardial fibrosis is characterized by expansion of the extracellular matrix and 
accumulation of interstitial collagen marked by increases in circulating PINP and 
PIIINP.21,22 Cardiac MRI with T1 mapping is a sophisticated technique we have validated 
to quantify myocardial extracellular volume (ECV) and is a standard method for non-
invasive assessment of myocardial inflammation and fibrosis in lieu of an 
endomyocardial biopsy. Data suggests a relative increase in ECV by 10% is linked to a 
50% increase in adverse CV events.23 Myocardial fibrosis contributes to impaired 
diastolic relaxation and is a key mediator of diastolic dysfunction. Myocardial damage is 
linked to a 4-fold increase in heart failure risk.24 Importantly, the progression to heart 
failure is preventable, as pathological remodeling in the myocardium related to these 
fibrotic changes is reversible25-27 prior to establishment of diastolic dysfunction. In a 
cross-sectional study, Holloway et al. demonstrated that a majority (76%) of ART treated 
HIV patients had evidence of myocardial fibrosis on cardiac MRI compared to only 14% 
of well-matched non-HIV patients.28 Furthermore, a meta-analysis reported that diastolic 
dysfunction is prevalent in approximately 43% of HIV patients.29 Despite the alarming 
prevalence of myocardial fibrosis30 and diastolic dysfunction in HIV, no longitudinal 
studies have been performed to date assessing changes in myocardial structure in HIV 
over time, nor have there been any interventional studies of strategies to regress 
changes in cardiac remodeling to prevent CV events in HIV.  
 

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Mechanistic pathways leading to impaired cardiovascular structure and function 
in HIV are not well understood. The conventional paradigm for CVD presumes a 
higher prevalence of traditional risk factors. Indeed, dyslipidemia, hypertension, and 
diabetes are all more prevalent in HIV vs. non-HIV patients, and smoking rates are 
increased almost 2-fold among HIV patients, but these traditional risk factors only 
account for 25% of the increased risk of CVD in the HIV compared to the non-HIV 
population.3,4 In addition, emerging studies have provided insight on the benefit of ART 
use on CVD, such that viral suppression may be associated with a reduction in CV 
events.31 While immunologic control is important for CVD risk reduction, ART alone only 
partially mitigates this risk. Therefore, our knowledge of CVD in HIV is incomplete, and 
significant advances in this area are needed to further our understanding of specific HIV-
related mechanisms that may account for the excess burden of CVD. Mechanisms 
implicated in cardiac injury and dysfunction specific to controlled HIV infection may 
include persistent inflammation and immune activation or abnormal fat redistribution. In 
this grant, building on data from our existing grant, we hypothesize that increased RAAS 
activation in HIV may be a mediator of structural and function changes of the heart either 
directly through vascular injury or indirectly through stimulating a pro-inflammatory, pro-
fibrotic milieu.  
 
Evidence from animal studies and studies of non-HIV patients demonstrate that 
MR activation is linked to vascular dysfunction, vascular inflammation, and 
subclinical atherosclerosis. We and others have shown that MR activation leads to 
coronary vascular inflammation and dysfunction.32 Aldosterone mediated vascular injury 
is associated with an increase in inflammatory and vascular markers, such as MCP-1, 
IL-6, ICAM and PAI-1.33-35 In animal models of aldosterone mediated injury, such as 
rodents infused with Ang II and a NO synthase inhibitor36 and double transgenic rats for 
the human renin and angiotensinogen genes,37 blocking the actions of aldosterone with 
an MR antagonist or removing the aldosterone source through adrenalectomy reduces 
vascular damage and myocardial inflammation. These beneficial effects of MR blockade 
are independent of changes in blood pressure (BP).38 We have shown that diabetics 
without known CAD have impaired CFR and subsequently, treatment with a MR 
antagonist (eplerenone or spironolactone) improves coronary vascular function marked 
by improvements in CFR.39,40 Moreover, aldosterone may have direct effects on 
atherogenesis through increased oxidative stress and foam cell formation.41 Under 
condition of RAAS activation, development of atherosclerotic plaque increased 3-fold in 
apolipoprotein E-deficient mice.42 Moreover, MR blockade attenuated the pro-
atherogenic effects of RAAS activation43 by reducing oxidation, cholesterol 
accumulation, and inflammation. Other animal studies have similarly shown that 
eplerenone can inhibit atherosclerosis41 independent of BP lowering effects.44 Data in 
mice also show that aldosterone promotes T cells and monocyte infiltration into plaque 
prone regions and is associated with an unstable lipid laden and inflammatory plaque 
phenotype prone to rupture.45 Moreover, eplerenone reduces expression of IL-6 and 
MCP-1 in macrophages during early atherosclerosis development in mice.46 While a few 
human studies in non-HIV patients have been performed to support these preclinical 
findings linking aldosterone to plaque progression,47 no studies have evaluated MR 
activation and blockade on CVD indices in HIV, a population in whom RAAS activation 
may indeed contribute to abnormal coronary vasculature and progression of plaque.  
 
MR activation is also related to myocardial fibrosis and diastolic dysfunction. 
Animal studies have demonstrated that MR activation by aldosterone or 

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deoxycorticosterone acetate contributes to cardiac fibrosis and adverse remodeling of 
the coronary vasculature, independent of BP changes48 Moreover, preclinical data show 
that Ang II-stimulated changes in myocardial inflammation, myocardial necrosis and PAI-
1 expression in coronary endothelial cells were attenuated with MR blockade.36,38 
Myocardial fibrosis secondary to tissue injury by aldosterone can increase LV 
hypertrophy, reduce vascular compliance, and impair diastolic dysfunction. Indeed, MR 
blockade with spironolactone or eplerenone markedly improves CV morbidity and 
mortality related to heart failure in human studies,49-51 and may have more efficacy in the 
HIV subpopulation in whom we have demonstrated significant RAAS activation. We 
have shown that 24 hour urinary aldosterone excretion is correlated with ECV in 
diabetics.52 Studies in non-HIV patients complement these findings, demonstrating that 
MR blockade improves diastolic dysfunction,49,53,54 and is also linked to improved 
markers of collagen turnover and myocardial fibrosis in those with the metabolic 
syndrome.53 Similar results were confirmed among non-HIV patients, in whom 
eplerenone treatment improved measures of diastolic dysfunction and reduced markers 
of collagen turnover, including P1NP and PIIINP.55,56 Lipocalin 2 has been implicated in 
mediating the profibrotic and tissue remodeling activity of mineralocorticoids through its 
action in cardiac myocytes, endothelium, and vascular smooth muscle cells.57 In human 
studies, lipocalin 2 is associated with adverse CV events58 and correlates with 
aldosterone levels.59 Taken together, this evidence suggests that MR blockade may 
have significant benefit in HIV, a population with a high prevalence of myocardial fibrosis 
and diastolic dysfunction.  
 
Increased RAAS activation contributes to inflammation and metabolic 
complications in HIV, suggesting the utility of MR blockade for CVD in HIV. 
Together the Co-PI’s Grinspoon and Adler conducted the first comprehensive 
investigation of the RAAS in HIV. Initial data revealed increased urinary aldosterone in 
HIV vs. controls in association with increased visceral adipose tissue (VAT) and 
HbA1c.60 New published data from the Co-PIs further suggests that HIV subjects with 
relative increases in abdominal fat accumulation demonstrate significantly increased 
RAAS activation under standardized dietary and posture conditions. Also, increases in 
aldosterone are associated with insulin resistance.61 Furthermore, markers of 
inflammation, including hsCRP and IL-6, are increased under conditions of RAAS 
activation among HIV patients. Indeed, these novel studies performed in HIV serve as a 
paradigm to suggest a previously unexplored mechanism through RAAS activation by 
which HIV patients with an adverse metabolic phenotype are predisposed to CVD. 
Indeed, increased VAT is a predictor of subclinical CVD in HIV62 and, this proposal will 
test the hypothesis that increases in RAAS activation contributes to CVD in HIV. We will 
obtain novel information on the link between RAAS activation and myocardial and 
vascular injury in HIV through these studies. To that end, other studies have indicated 
that aldosterone levels independently correlate with CV mortality.63,64 Importantly, we will 
assess for the first time in HIV the specific contribution of MR signaling to multiple 
cardiac endpoints, including impaired CFR, myocardial fibrosis, diastolic dysfunction, 
and subclinical atherosclerosis, by applying MR blockade in an interventional trial among 
HIV patients selected based on the presence of metabolic abnormalities associated with 
RAAS activation and related subclinical atherosclerosis.  
 
Summary and Implications: MR signaling may have an adverse role in CVD through 
vascular dysfunction, abnormal collagen deposition, vascular and myocardial 
inflammation, and increased oxidative stress65. The burden of structural and functional 

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heart disease in HIV is greater compared to the general population. We have 
demonstrated significant RAAS activation in HIV patients with metabolic abnormalities, 
including increased visceral adiposity and insulin resistance, and suggest that this 
unique physiology may contribute to a metabolic phenotype that is pro-inflammatory, 
pro-fibrotic, and pro-atherogenic. It is plausible that a cascade of excess MR activation in 
HIV potentiates cardiac injury and dysfunction. Moreover, there is relevant data to 
support testing the efficacy of MR blockade in managing impaired myocardial perfusion, 
myocardial fibrosis, diastolic dysfunction, and plaque. The grant will provide new 
mechanistic insight and enhance our understanding of CVD in HIV. We will take 
advantage of advanced imaging methods to permit a non-invasive longitudinal 
assessment of structural and functional CV defects in HIV to add new information to the 
field. This is an ideal proposal aiming to integrate several manifestations of CVD in HIV 
through a novel hormone pathway. The clinical utility of MR blockade could have far 
reaching effects towards overall CV risk reduction in HIV, and such studies could serve 
as a model for other at-risk metabolic groups. 
  
II.  Specific Aims 
We will perform a randomized double-blind study among HIV subjects with increased 
visceral adiposity and subclinical atherosclerosis, administering eplerenone vs. placebo 
for 12 months. We will provide all subjects with lifestyle modification throughout the 
study. We hypothesize that adding eplerenone to lifestyle modification will significantly 
improve key indices of cardiac structure and function.  
 
Among the large population of HIV patients in whom we have shown renin-angiotensin-
aldosterone activation and subclinical atherosclerosis, we will determine:  
 
❖ Specific Aim I: The effect of MR blockade on myocardial perfusion. 
      We hypothesize:  
a) MR blockade will improve coronary flow reserve (CFR) on cardiac positron emission 
      tomography (PET) or stress myocardial blood flow (sMBF) on cardiac magnetic    
       resonance imaging (MRI). 
 
b)  MR blockade will reduce markers of vascular dysfunction. 
 
❖ Specific Aim II: The effect of MR blockade on myocardial inflammation and 
fibrosis. We hypothesize:  
a) MR blockade will reduce myocardial extracellular volume fraction, a measure of 
myocardial fibrosis and inflammation, assessed by serial myocardial T1 mapping 
cardiac magnetic resonance imaging (MRI). 
b)   MR blockade will improve markers of inflammation and immune activation. 
c)   Reduced myocardial fibrosis and inflammation resulting from MR blockade will      
      relate to improvements in diastolic dysfunction evaluated through diastolic strain  
      by tagged myocardial imaging on cardiac MRI.  
 
❖ Specific Aim III: The effect of MR blockade on coronary plaque.  
We hypothesize:  
a) MR blockade will result in plaque regression and reduced high risk plaque     
      Morphology on coronary computed tomography angiography (CTA). 
     b)  Baseline CFR will relate to coronary plaque features in HIV patients with subclinical  
    atherosclerosis.   
     c)  Improvements in coronary plaque with MR blockade will relate to improvements in     
          CFR and inflammation. 

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Optional Substudy-- 
❖ Specific Aim IV:  The effect of RAAS activation on systemic inflammation and 
specific indices of arterial inflammation.  
      We hypothesize:  
a)  Markers of systemic and arterial inflammation will be increased during the RAAS   
     activated state carefully controlled conditions of sodium restriction) when compared     
     to the RAAS suppressed state (under carefully controlled conditions of sodium      
     loading). 
 b) Higher serum aldosterone levels during the RAAS activated state (under carefully   
     controlled conditions of sodium restriction) will be related to greater in situ arterial  
     inflammation measured by aortic TBR using cardiac 2-deoxy-2-18F-     
     Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18F-   
     FDG-PET/CT).  
 
❖ Specific Aim V: The effect of MR blockade on arterial inflammation.  
We hypothesize:  
a)  Treatment with MR blockade for 12 months will reduce in situ arterial inflammation     
      measured by aortic TBR using cardiac18F-FDG-PET/CT. 
b)  Treatment with MR will reduce markers of systemic and vascular inflammation. 
c)  Changes in aortic TBR will be related to changes in markers of arterial inflammation.  
 
 
Optional Study for those who do not qualify following both screen visits— 
❖ Specific Aim VI: The degree of inflammation and cardiometabolic disease 
among those with/without visceral fat and those with/without coronary plaque  
We hypothesize: 
a)   Worsening markers of inflammation and heart disease across the spectrum stratified 
by presence and absence of excess VAT and presence and absence of coronary plaque 
(i.e  increased worsening across the following groups: low VAT/absence of plaque, low 
VAT/presence of plaque, high VAT/absence of plaque, high VAT/presence of plaque).  
 
 
III. Subject Selection 
Inclusion/Exclusion: 
Inclusion Criteria: Up to 160 HIV male and female subjects will be consented to 
achieve the number of evaluable subjects. 42 subjects will be consented for the optional 
study.  
Subjects will be included for: 
1)  Ages 40-65 years 
2)  Antiretroviral use (ART) >12 months and viral load <100 copies/mL 
3)  VAT> 110cm2  
 
Exclusion Criteria:  
1) Antihypertensive use including, ACE Inhibitor, ARB, MR blockade, diuretic, potassium    
    (K) supplementation; or BP>140/90 mmHg. Stable use (>3 months) of beta-blockers    
    or calcium channel blockers (CCB) (except verapamil) is allowed. 
2) Unstable statin use <12 months. Stable use (>12 months) is allowed.  
3) Use of full dose ritonavir, nelfinavir, clarithromycin, and other strong inhibitors of   
    CYP3A4, as well as CYP3A4 inducers.  
4) Continuous oral steroid use (equivalent to prednisone > 5 mg daily) within the last 3        
   months. 

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5) Uncontrolled diabetes requiring insulin and/or HbA1c > 7.5%.  
6) Creatinine (Cr) > 1.5 mg/dL or estimated GFR<60 mL/min/1.73m2. 
7) K > 5.5 mEq/L. 
8) Hemoglobin < 10 g/dL. 
9) Known liver disease or ALT >3x ULN. 
10) History of congestive heart failure, stroke, myocardial infarction, or known coronary  
      artery disease. 
11) Pregnant, actively seeking pregnancy or breastfeeding. Women of childbearing  
      age may be on a non-hormonal form of contraception.  
12) Estrogen, progestin derivative, or other sex steroid use within last 3 months. Stable     
      physiologic testosterone replacement (> 3 months) is acceptable. 
13) Current bacterial or other infections. 
14) Active substance abuse. 
15) Significant radiation exposure over the course of the year prior to randomization  
      (e.g., radiation therapy, PCI, catheter ablation of arrhythmia) within 12 months of  
      randomization. 
16) Previous reaction or contraindication to gadolinium. 
17) Coronary artery luminal narrowing >70% on coronary CTA.  
 
Source of subjects and recruitment methods: 
Participants will be recruited from community flyers and announcements at HIV focused 
community centers, community newspaper advertising, community on-line websites, 
Partner’s- affiliated Recruitment Tools, and referrals from infectious disease physicians 
and primary care physicians familiar with the study and through the utilization of the 
Partners Research Data Registry (RPDR).  Potential participants, from all referral 
sources, will contact the study investigator directly by phone for a pre-study evaluation 
via telephone to determine eligibility. In addition, if a provider obtains a subject’s 
permission for us to contact them directly, then we may do so.  We will not contact any 
subjects for whom permission was not obtained in advance by their medical providers.  
For RPDR, we will perform an RPDR search to identify patients with HIV infection, ages 
40-65 without known diagnosis of Cardiovascular Disease.  We will subsequently review 
the resulted medical records to hone in on those that match our inclusion/ exclusion 
criteria. We will directly contact patients who have agreed to be approached by research 
staff as part of the Research Opportunities Direct to You (RODY) Program.  For patients 
not enrolled in RODY, we will contact each eligible patient’s provider to request that s/he 
mention the study to the patient and ask that individual for permission to be contacted by 
the study staff.  Only if permission is granted, we will call the patient to conduct a phone 
screen and provide study information. 
 
IV. Subject Enrollment 
Informed consent will be obtained at the screening visit by a licensed physician or nurse 
practitioner, prior to any procedures or interventions. Potential research subjects will 
have the entire protocol explained in detail and study investigators will review the 
consent form item by item, answering any and all questions. Once risks and benefits 
have been reviewed and subjects have agreed to participate by signing the consent, the 
screening visit will continue as described in the subject selection section. Only patients 
capable of providing informed consent will be enrolled. Once final eligibility has been 
determined subjects will be scheduled for a baseline visit.   
 
Optional Study Participation: 

MIneralocorticoid Receptor Antagonism for CardiovascuLar hEalth in HIV 
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Upon confirmation of eligibility, subjects will be given the option through a formal 
consenting process to participate in the substudy prior to randomization. Participation in 
the main study will not be affected if subjects choose to decline participation in the 
substudy; however, subjects withdrawn from the main study will be withdrawn from the 
substudy.  
 
If subjects do not qualify for the main study following completion of both screening visits, 
subjects will be given the option to participate in an optional blood sampling visit.  
 
Treatment assignment and randomization: 
During the Baseline Visit randomization will be done. Subjects will be randomized 1:1 to 
receive eplerenone PO 50mg daily or identical placebo for 12 months. The 
randomization list, stratified by gender, statin use, and presence of plaque will be 
generated by the biostatistician and kept by the research pharmacy. Daily dosing starts 
at 50 mg for the first week to avoid hypotension and will be increased to 50 mg twice 
daily at the 1 week safety visit. The study will be double-blinded. All subjects will receive 
lifestyle modification as described below.   
 
Prior to randomization in all cases, the subject’s primary care physician will be consulted 
regarding the appropriateness of the protocol including the lifestyle modification program 
with the subject’s permission. Subjects are not eligible if they do not meet all of the 
enrollment criteria. 
 
In the event that a subject wishes to withdraw from the study, the subject will be asked to 
return all unused study medication. 
 
V.  Study Procedures 
Data Collection 
Screening Visit 1 (to determine eligibility): 
We will obtain: 
1) Informed consent, history and physical, urine pregnancy test for females.  
2) Blood for Cr, K, ALT, CBC, HbA1c, and HIV viral load.  
 
Screening Visit 2 (to determine eligibility): Subjects will present after a 12 hr fast. If 
eligible from Screening Visit 1, we will obtain: 
1)  Urine pregnancy test for females as appropriate. 
2) Coronary CTA for coronary plaque assessment. (This will not be performed if 
the subject has a previous reaction or contraindication to iodine-containing contrast 
media).  
3) CT Abdomen for single slice screening at L4 for VAT determination.  
 
Optional Blood Sampling Visit (For those who do not qualify after both screening 
visits): Subjects will present after an overnight 12 hr fast. 
1)  Fasting blood for markers of heart disease and inflammation 
 
Bionutrition Visit (prior to both Baseline Visit 1 and 12 Month Visit):  Subjects will 
be tested on an ad lib diet, after an overnight 12 hr fast. We will obtain: 
1)   Blood for Cr, K, lipids, glucose, insulin, CD4/8, HIV viral load (12 Month Visit only) 
and biomarkers for vascular dysfunction (sICAM, sVCAM), inflammation/ immune 
activation (CRP, IL6, MCP-1, sCD14, sCD163), subclinical injury (BNP, high 

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sensitivity cardiac troponin T [hs-cTnT]), and fibrosis (galectin-3, cardiotrophin 
1[CT1], lipocalin 2, PINP, PIIINP). DNA collection for genetic testing is optional. 
2)   24 hr urine collection for sodium (Na) and Cr for sodium balance will be started one 
day prior to the visit. In consultation with the bionutritionist, broth packets will be 
given to achieve standardized sodium conditions (urinary Na >200mmol/24 hr) for 
Baseline Visit 1 and 12 Month Visit. Urine pregnancy test for females as appropriate. 
3)  Standardized lifestyle counseling as per goals derived from the AACE and NCEP-
ATP III guidelines and modeled after the Diabetes Prevention Program. 
4)   Coronary CTA only at the end of study visit prior to 12 Months. (This will not be 
performed if the subject has a previous reaction or contraindication to iodine-
containing contrast media).  
5)   Optional Consent for substudy. 
 
Baseline Visit 1 (Imaging): Subjects will present after a 12 hr fast on 2 consecutive 
days. CCB will be held 36 hrs prior to coronary perfusion assessment. 
1)   24 hr urine will begin on the morning of this visit for volume, Na, K, Cr, cortisol and 
aldosterone excretion rate.  
2)   STAT serum pregnancy test for females as appropriate.  
3)   Urine Na and Cr for sodium balance.       
4)   Interval history and physical, including orthostatics.  
5)   Cardiac PET to assess CFR. 
6)   Subjects will begin fast and lie supine overnight. 
7)   Fasting blood for PRA, serum aldosterone, K. DNA collection for genetic testing is 
optional. 
8)   Cardiac MRI for ECV, endo to epicardial flow (perfusion) ratio, diastolic and systolic 
strains and peak strain rates, LVEF and LV mass. 
9)   Abdominal MRI for VAT and SAT.  
 
Baseline Visit 2 (RAAS Characterization): After Baseline Visit 1, subjects will be 
placed on an isocaloric low sodium diet for 6 days prepared by the metabolic 
phenotyping core at the BWH Center for Clinical Investigation for assessment of RAAS 
activation. Subjects will be asked only to consume the prescribed diet, containing 10±2 
mEq Na+, 100±2 mEq K+, and 1000±50 mg Ca2+ per 24 hours.  
1)   24 hr urine will begin on the morning of this visit for volume, Na, K, Cr, cortisol, and    
      aldosterone excretion rate.  
2)   Urine pregnancy test for females as appropriate.  
3)   Urine Na and Cr (rescheduled if subject is not in sodium balance). 
4)   Interval history and physical, including orthostatics.  
5)   Subjects will begin fast and lie supine overnight. 
6)   Fasting blood for PRA, serum aldosterone, K. DNA collection for genetic testing is 
optional. 
7)   Resume ad lib diet and administer study medication (eplerenone vs. placebo) to be 
started on the following day. 
 
Substudy Visit 1 (Optional): Subjects will present on a low carbohydrate diet, after an 
overnight 12 hr fast. We will obtain: 
1)   STAT serum pregnancy test for females as appropriate.  
2)   Cardiac 18F-FDG-PET/CT to assess arterial inflammation. 
 
Randomization and Blinding: Subjects will be randomized 1:1 to receive eplerenone 

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50mg daily or identical placebo for 12 months. The randomization list, stratified by 
gender, statin use and presence of plaque will be generated by the biostatistician and 
kept by the research pharmacy. Daily dosing starts at 50 mg daily for the first week to 
avoid hypotension and will be increased to 50 mg twice daily at the 1 week safety visit. 
The study will be double-blinded. All subjects will receive lifestyle modification as 
described below.   
 
Safety Visits (1 wk, 2 wk, 4 wk, 3 mo, 6 mo, 9 mo post baseline visits): Subjects will 
only present after an overnight 12 hr fast for the 6 month visit. All safety visits include:  
1)  Urine pregnancy test for females.  
2)  Interval history and physical, including vitals. 
3)  Blood for Cr, K. Blood for markers of heart disease and inflammation for the 6 month 
visit only.  
4)  Collection of used study drug and provision of new supply. 
5)  Standardized lifestyle counseling as per goals derived from the AACE and NCEP-
ATP III guidelines and modeled after the Diabetes Prevention Program. At the 1 week 
visit, the study dose will be escalated to 50mg twice daily as tolerated based on blood 
pressure and labs.  
 
12 Month Visit: Same as Baseline Visit 1 
 
Substudy Visit 2 (Optional): Same as Substudy Visit 1 
 
COVID19 Contingency Plan: MGH and BWH have instituted restricted visits for 
research purposes in response to the evolving COVID-19.  These restrictions have 
prompted the following changes to the study:  
 
1) We may conduct visits remotely until restrictions are lifted. Remote visits will be 
conducted over zoom video conferencing or telephone and every attempt will be made 
to keep the visit schedule the same. Changes may occur to the visit schedule due to 
factors related to covid19. During these visits, someone from the study staff will contact 
the subject (via zoom video conferencing or telephone) and may conduct the following 
research activities: 
 
• 
Consenting* 
• 
Obtaining information about past and present health 
• 
Questionnaires 
• 
Lifestyle Counseling 
• 
Obtaining information related to safety assessments  
 
2) We may ship study drug directly to the subject.  
 
3) If blood work cannot be obtained at the study site, we may ask the subject to have 
labs performed locally. We will provide a lab requisition and help locate a facility.  
 
4) We will try to arrange for assessments to occur remotely and continue to follow the 
visit schedule. Some study procedures require a visit to the study site, for example, 
imaging procedures. We may provide the subject with additional study drug until we are 
able to perform the study procedure, and this may extend the visit schedule. If a study 
procedure requires an in-person visit and cannot be scheduled at the study site due to 

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COVID19 policies, then the procedure may be omitted.   
 
 
*COVID19 Contingency Plan for Informed Consent: 
 
A consent form may be mailed or emailed to the subject and a licensed physician 
or nurse practitioner will arrange a phone call or zoom video conference with the subject 
to review the consent form in detail. The consent form will be signed and completed via 
one of the following options: 1) If the subject has electronic capabilities/internet to use 
REDCap, the consent form will be electronically signed by both parties and a PDF of the  
consent form will be available for both the subject and the licensed physician or nurse 
practitioner, or 2) The subject will sign the consent form during the phone discussion and 
either mail/email the signed form to study staff or bring the signed form to the next in 
person visit at which time the consent form will be signed by the licensed physician or 
nurse practitioner, or 3) To minimize exposure time between the subject and study team, 
an iPad may be offered to the subject to perform a zoom video conference with the 
licensed physician or nurse practitioner to discuss the consent form prior to meeting in 
the same room to sign the consent form. Study procedures will not be performed prior to 
obtaining informed consent and obtaining a copy of the signed consent form. 
 
Study Procedures  
Computed Tomography (CT) Abdomen  
Images with be acquired via single-slice acquisition through L4 with tube current of mA, 
voltage of 80kV and 70mAs, slice thickness 10 mm, and 45 cm field-of-view.  
 
Coronary Computed Tomography Angiography (CTA) 
Contrast-enhanced CCTA allows for non-invasive assessment of atherosclerotic plaque 
burden and morphology. Image acquisition will take place at MGH using the SOMATOM 
Definition Flash, a dual source 128 detector row CT scanner, or the SOMATOM Force, a 
dual source 196 detector-row CT scanner (Siemens Healthineers, Forchheim, 
Germany). Semiautomated reference tube current selection and exposure control 
(CAREDose 4D) are tailored to the subject’s body size, in conjunction with 
semiautomated reference tube potential (voltage) selection (CARE kV), with individually 
adapted exposure settings on a per-patient basis.  Prospective ECG-triggered axial-
sequential or retrospective ECG-gated spiral with adaptive pulsing scan modes are used 
based on the heart rate and rhythm.  Iterative image reconstruction algorithms allow for 
further reductions in radiation dose. 
 
The CCTA protocol is as follows, and is based on the standard clinical CCTA protocol at 
MGH:  Prior to imaging, intravenous (IV) access will have been obtained in an arm or 
hand vein, usually in the right antecubital vein. The subject’s blood pressure will be 
taken, and ECG leads will be attached to monitor heart rate and rhythm.  Sublingual 
nitroglycerin (0.3-0.9 mg, typically 0.6 mg) or transdermal nitroglycerin (0.6-0.8 mg/hr for 
~45 minutes) will also be administered as per standard protocol for cardiac CT scans. 
Contraindications to nitroglycerin include known narrow angle glaucoma, hypotension 
with systolic blood pressure < 90 mm Hg, known severe aortic stenosis, or use of 
phosphodiesterase type 5 inhibitor (e.g. sildenafil, tadalafil, vardenafil) within the 5 days 
prior to scan.  A prospectively-ECG triggered noncontrast CT of the heart is obtained to 
measure coronary calcium. The test bolus method will be used to plan the CTA timing, 
via a test bolus injection of nonionic iodinated contrast medium (approximately 20 ml), 
followed by a flush of saline solution (approximately 40 ml). Contrast-enhanced CT 

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acquisition will then take place. Based on subject size, 60-100 ml of nonionic iodinated 
contrast (iopamidol 370 g/cm3, Isovue 370, Bracco Diagnostics, Princeton, NJ) will be 
injected, followed by a flush of 40 ml of saline solution. After a delay based on the test 
bolus, a CT acquisition will be performed from the aortic arch to the diaphragm: tube 
voltage 70 - 120 kVp, tube current-time product reference 320 mAs, detector collimation 
2 x 128 x 0.6 mm or 2 x 196 x 0.6 mm. A number of high-resolution images of the heart 
at slightly different time-positions within the cardiac cycle will be reconstructed, of which 
the best phase will be used to evaluate the coronary artery lumen, plaque distribution, 
and plaque morphology. 
 
Cardiac Positron Emission Tomography (PET)  
Regional and global coronary blood flow will be assessed using PET imaging. 
Vasoactive medications and beta-blockers will be withheld on the morning of the study. 
Subjects will be allowed to continue using nitroglycerin as needed. Studies will be 
performed after at least 4 hours of fasting. The protocol will take approximately 2.5 
hours, including patient preparation. Regional coronary blood flow will be measured at 
rest and during an intravenous (IV) infusion of regadenoson (0.4mg) or adenosine (0.14 
mg/kg/min) using 13N-ammonia as a flow tracer. After IV administration of 13N-
ammonia (20 mCi), serial images will be acquired for 20 min, as previously described. 
After 30 min, IV regadenoson or adenosine will be infused for 4 minutes. Two minutes 
into the regadenoson or adenosine infusion, a second dose of 13N-ammonia (20mCi) 
will be injected and images recorded again in the same sequence. HR, BP, and 12-lead 
ECG will be recorded at baseline and every minute during and after the infusion of 
regadenoson or adenosine. All images will be analyzed by an expert in cardiac PET 
blinded to treatment assignment. 
  
Cardiac Magnetic Resonance Imaging (MRI)  
T1 imaging before and after contrast, using a breath-hold, modified Look- Locker 
imaging (MOLLI) technique, will be used for mapping of the total and segmental 
extracellular volume fraction to detect expansion of the extracellular matrix. Typical 
MOLLI acquisition parameters are: TR/TE=2.14/1.07 ms, flip angle=35º, FOV= 
340x255mm, matrix=192x144, 107 phase encoding steps, interpolated voxel size= 
0.9x0.9x8mm, parallel acceleration factor=2 with 24 reference lines (iPAD), cardiac 
trigger delay TD=500ms; 206 ms acquisition time per SSFP image read-out. The pre-
contrast T1 mapping will use a 5(2)-3 MOLLI scheme, while the post-contrast T1 
measurements will use a 4(2)-3(2)-3(2) scheme, where the numbers in brackets indicate 
the duration of the rest period as a multiple of the R-to-R duration. The post-contrast T1 
measurements are interleaved with the other MR protocol components, such that T1 
measurements are not performed within less than 5 minutes of a contrast injection to 
assure contrast-equilibrium between tissue and blood. Multiple T1 measurements are 
used with regression analysis to obtain an accurate estimate of extracellular volume 
(ECV) fraction, thereby improving upon the precision of “two-point” measurement 
protocols.66 Only R1 data-pairs with R1 in blood < 3.5 s-1 will be used to meet the 
conditions of fast transcytolemmal water exchange, underpinning the linear model for 
ECV. 67 ECV will be multiplied by LV mass index and reported as ECMi (g/m2). The T1 
protocol comprises one pre-contrast measurement, and 3 post contrast measurements 
as outlined above. Microvascular coronary function via a combination rest/stress MRI 
perfusion study will be quantified. Study subjects will be administered regadenoson (5 ml 
containing 0.4 mg regadenoson bolus via IV, followed by flush) or adenosine (400 
microgram bolus via IV, followed by flush). A saturation-recovery prepared fast 

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“TurboFLASH” gradient echo-technique, with iPAT (with mSENSE) acceleration (x2) will 
be used to measure perfusion at rest and after vasodilatory stress in three slices (basal, 
mid, apical levels) with an in-plane resolution of 2.2 x 2.2 mm in three short-axis slices, 
using TR/TE/flip = 2.3/1.0/18°; 10 msec delay after saturation before image read-out; 
linear phase-encoding order. In addition, a low-resolution TurboFLASH image is 
acquired within 50 ms during each heart-beat at the basal level. This low resolution 
image has a T1-weighting that allows to measure the arterial input function (AIF) without 
significant signal saturation68. (Siemens software patch WIP578 for syngo MR B17). The 
saturation-recovery time for the AIF readout is kept to < 20 ms. The software also 
automatically generates motion-corrected images (in addition to the “raw” images), 
which substantially reduces the post-processing time for quantification of myocardial 
perfusion (reserve). A contrast bolus dosage of 0.06 mmol of Dotarem (gadoterate 
meglumine, Guerbet,Inc.) is injected to allow coronary blood flow quantification using the 
arterial input measured with the low-resolution AIF “scout”, and keeping arterial and 
myocardial signal saturation to < 5%. (We use a dosage of 0.06 mmol/kg for this reason, 
rather than 0.1 mmol/kg used by Gatehouse et al68, though this dosage is fully adequate 
for analyzing myocardial contrast enhancement.). Rest perfusion imaging will be 
performed > 20 minutes after stress perfusion imaging. We will quantify coronary blood 
flow, as we have done previously.69,70 The rationale for acquiring perfusion images with 
MRI in parallel with the PET studies, is the higher spatial resolution of MRI compared to 
PET to assess myocardial blood flow in the endocardial layer, and also determine the 
ratio of endo- to epi-cardial flows, as a marker of ischemia. For post-processing, the 
perfusion images will be segmented along the endo- and epi-cardial borders of the LV, 
and a reference point will be placed at the anterior LV/RV junction. Coronary blood flow 
will be quantified by model-independent deconvolution of the myocardial signal curves 
with the AIF. Myocardial signal curves for endo- and epicardial layers in 16 segments of 
the AHA segmentation model will be analyzed. All images will be analyzed by an expert 
in cardiac MRI blinded to treatment assignment. 
 
Abdominal MRI 
Images will be acquired using an axial T1-weighted fat suppressed pulse sequence 
obtained at the level of L4 vertebral body. Abdominal visceral and subcutaneous fat 
areas from MRI and CT are determined based on offline analysis of tracings obtained 
utilizing commercial software (Vitrak, Merge e/Film). 
 
Nutritional Analysis and Dietary Protocol 
Protein, carbohydrate, fat, micronutrient, dietary supplements and alcohol intake will be 
determined from 4-day food records (Nutrition Data systems). For 6 days prior to 
Baseline Visit 2 (RAAS characterization), subjects will be provided low sodium meals 
and snacks (10 mEq daily sodium, 100 mEq potassium, 1000 mg calcium, water intake 
ad lib) and they will be asked not to consume any food not provided to them, including 
no caffeine or alcohol. For 3 days prior to Baseline Visit 1 and 12 Month Visit, subjects 
will be provided sodium supplements through broth packets as needed to achieve 
urinary Na >200mmol/24 hr, and they will be asked not to consume any food not 
provided to them, including no caffeine or alcohol. Urine aliquots for sodium and 
creatinine and 24hr urine sodium will be measured for the period immediately prior to 
each visit to ensure compliance with the diet.   
 
Lifestyle Modification 
Goals derived from the AACE and NCEP-ATP III guidelines and the Diabetes Prevention 
Program are as follows: <35% calories from fat, < 7% calories from saturated fat, up to 

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10% calories from polyunsaturated fat, reduction of trans fatty acid intake, up to 20% 
calories from monounsaturated fat, and 25-35g of fiber per day. 3 hrs of physical 
activity/week at moderate intensity. The curriculum is modeled after the Diabetes 
Prevention Program.  Subjects will complete lifestyle sessions at the Clinical Research 
Center at MGH with nutritionists trained to implement the curriculum. The curriculum will 
be introduced and reinforced until the completion of the study.  
 
Optional Substudy: 
Cardiac 2-deoxy-2-18F-Fluorodeoxyglucose Positron Emission Tomography/ 
Computed Tomography (18F-FDG-PET/CT)  
An approach to detecting macrophage activity in atherosclerotic plaques uses FDG as 
the contrast radiotracer for positron emission tomography (PET). FDG competes with 
glucose for uptake into metabolically active cells, including macrophages in 
atherosclerotic plaques, and is trapped inside cells after phosphorylation. FDG-PET can 
image metabolic activity (as a marker of plaque inflammation) quantitatively in 
atherosclerotic plaques71,72, has been shown to have high reproducibility73, and 
correlates with histologic data72. Taking advantage of the myocardium’s preference for 
free fatty acids over glucose as an energy source, to minimize myocardial glucose 
uptake in order to better visualize coronary plaque activity, patients will be asked to 
adhere to an Atkins style diet for the evening prior to imaging and then to fast overnight. 
A fasting glucose will be checked prior to the start of the study. Cardiac PET/CT imaging 
will be performed two hours following intravenous administration of approximately 10mCi 
of 18F-FDG. Imaging will be performed using a Siemens Biograph PET/CT system 
(Siemens Medical Solutions, Forchheim, Germany). Semi automated co-registration of 
PET and CT images will be accomplished using the Siemens MultiModality WorkPlace 
TrueD (Forchheim, Germany).  Once co-registered, the standardized uptake value 
(SUV) of FDG will be measured in various arteries. The SUV is the decay-corrected 
tissue concentration of FDG (in kBq/ml) divided by the injected dose per body weight 
(kBq/g). Target-to-background ratio (TBR) will be calculated for each vascular segment 
as the segment SUV divided by vena cava or atrial blood SUV.  All images will be 
analyzed by an expert in cardiac FDG-PET/CT blinded to treatment assignment. 
 
 
VI.  Biostatistical Analysis  
Statistical Consideration:  Aim I: The primary endpoint is change in CFR assessed 
by cardiac PET or change in sMBF by cardiac MRI. Secondary endpoints will include 
the following: change in sICAM and sVCAM. Shapiro-Wilk test will be used to assess 
for normality of distribution, and variables that are not normally distributed will be 
appropriately transformed prior to inclusion in multivariable models. We will compare 
the change in CFR from months 0 to 12 between treatment groups (eplerenone vs. 
placebo) using student’s t-test for variables that are normally distributed or Wilcoxon 
rank sum test for variables that are not normally distributed. We will also compare 
changes in sICAM and sVCAM over 12 months between treatment groups using similar 
statistical methods. In all Aims, for subjects who withdraw after 6 months, but before the 
final 12 month visit, we will obtain biomarkers and imaging similar to that scheduled for 
the final 12 month visit if the subject agrees to have end of study testing. The analysis 
will be intention to treat (ITT). In order to properly handle subjects with missing 
outcomes (those who withdrew before 12 months), we will apply longitudinal linear 
mixed effects model analysis with random subject level intercepts and time slopes by 
which the longitudinal treatment effect can be examined by testing the significance of 

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time x treatment interaction, which will provide unbiased effect estimate under missing 
at random condition, which will be carried out by using augmented data sets created by 
multiple imputation. A sensitivity analysis will be performed to include only those 
subjects who completed the study. Baseline variables will be compared between 
treatment groups, and any variable that is statistically different between groups will be 
controlled for using multivariable modeling. It may be that subjects with more significant 
RAAS activation and dysregulation in aldosterone at baseline) are more responsive to 
eplerenone. We will phenotype the RAAS in subjects at the low sodium visit and, 
guided by this data, may use aldosterone levels prior to intervention as an index of 
RAAS activation and a covariate in assessing treatment response, to determine if 
eplerenone is more effective in the subpopulation with greater baseline aldosterone 
dysregulation and RAAS activation. Covariates that will be considered for inclusion in 
modeling, include variables that differ at baseline and those variables that may affect 
vascular dysfunction, inflammation, fibrosis and plaque (age, race, gender, BP, 
tobacco/illicit drug use, family history of CVD, lipids, and glucose), HIV parameters (viral 
load, CD4, and duration of HIV and ART use) and compliance. This will permit us to 
assess relevant factors that may mediate the effect of eplerenone on CFR in HIV and 
interactions between HIV and traditional risk factors contributing to eplerenone effects. 
Moreover, we will compare changes in CFR and vascular biomarkers over 12 months 
using regression analysis. We will perform Pearson’s correlation for variables that are 
normally distributed and Spearman’s correlation for variables that are non-normally 
distributed. If we see significant changes in specific biomarkers that correlate with 
changes in CFR, then we will run those specific biomarkers from stored serum at earlier 
time points (e.g. 6 months) to see if early changes in biomarkers can predict changes in 
CFR, as well as predict response to MR blockade. Biostatistician Role: The 
biostatistician will monitor data collection, quality and completeness of the study 
throughout all years of the grant. The biostatistician will create the randomization plan, 
using a permuted block algorithm, stratified for gender, statin use, and presence of 
plaque and provide the list to the study pharmacist (investigators will remain blinded). 
Identical placebo will be provided by the pharmacy. Sample Size Determination: 
Preliminary data from HIV subjects presented in this grant demonstrate a CFR 
1.74±0.73 (mean±SD) using cardiac PET Supportive data are also derived from a 
longitudinal study by our team using cardiac PET, showing mean±SD change of CFR in 
diabetics treated with spironolactone 0.33±0.83 vs. placebo: 0.02±1.03 over 6 months 
(mean SD=0.93).40 Given these data, we considered the range 0.73-0.93 SD to 
accurately reflect the potential variability of change in CFR for the proposed study. 
Based on this data, we now provide a range of detectable differences using 85% power 
and a revised increased sample size of 80 subjects, with an attrition rate of 15%, 
leaving 68 evaluable subjects. Thus, even choosing a conservative SD of 0.93, the 
study will be well powered to detect a difference in mean change of CFR of at least 
0.69. As our preliminary data, using PET, show that HIV patients have a mean CFR 1.7, 
an increase of CFR to 2.4 with eplerenone is a clinically relevant increase associated 
with decreased morbidity and mortality. For the sMBF and biomarkers, this study has 
85% power at a two-sided 0.05 α level to show a change in the variable of at least 0.74 
SD after treatment with eplerenone vs. placebo.  
 
Aim II: For this aim, the endpoint is change in myocardial ECV assessed by myocardial 
T1 mapping on cardiac MRI. Secondary endpoints will include the following: change in 
plasma IL-6, MCP-1, sCD163, sCD14 and serum hsCRP, galectin-3, cardiotrophin 1, 
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these specific endpoints. Similar to Aim I, changes in ECV and inflammatory/fibrosis 
biomarkers over 12 mos comparing eplerenone vs. placebo will be assessed using ITT 
and longitudinal linear effects modeling with imputation and sensitivity analyses. By 
regression techniques and covariate analyses, we will also assess whether 
improvements in ECV from MR blockade will relate to improvements in diastolic strain. 
Sample Size Determination: Thiara et al. show mean±SD ECV 0.28±0.04 vs. 
0.26±0.03 in HIV vs. non-HIV using cardiac MRI.30 To estimate the SD of change in 
ECV, we assumed an intrasubject longitudinal correlation over time r=0.7 among the HIV 
group, which results in a conservative SD estimate of 0.03. Based on this SD, the 
proposed study, with a revised sample size of 80 subjects and therefore 68 evaluable 
subjects considering a 15% attrition rate, will attain 85% power at a two sided α of 0.05 
to detect a difference of at least 0.02 in longitudinal means of ECV. Thus our study is 
well powered to find a significant difference between arms that is clinically relevant, as 
each 0.03 increase in ECV raises the risk for mortality or CV morbidity by 50%.23 For 
biomarkers, we have 85% power at a two-sided 0.05 α level to show a change of at least 
0.74 SD comparing eplerenone vs. placebo.  
 
Aim III: For this aim, the endpoint is change in noncalcified plaque volume assessed by 
coronary CTA. Secondary endpoints will include: change in high risk plaque morphology 
(numbers of low attenuation and positively remodeled plaque) by coronary CTA. 
Statistical algorithms as detailed in Aim I will be applied to these specific endpoints. 
Moreover, the relationship between baseline CFR and non-calcified plaque volume will 
be assessed. Lastly, we will also determine whether longitudinal changes in coronary 
plaque are associated with changes in biomarkers of inflammation and immune 
activation to understand the potential relationship of these inflammatory indices as 
markers of improved indices of the coronary vasculature in response to MR blockade in 
the HIV. Sample Size Determination: In our prior studies assessing plaque in HIV, the 
median [IQR] change of noncalcified plaque volume over 12 mos was 6.7[-6.5, 29.8] 
mm3.13  We assumed a conservative SD of 18mm3 taking the mean of the IQR. This 
study enrolling 80 subjects with 68 evaluable subjects will attain 85% power at a two 
sided α of 0.05 to detect a difference in noncalcified plaque volume of 13.3mm3 between 
eplerenone vs. placebo, a clinically relevant change. For biomarkers, this study has 85% 
power at a two-sided 0.05 α level to show a change of at least 0.74 SD after treatment 
with eplerenone vs. placebo.  
 
Aim IV: For this aim, the endpoint is change in MCP-1 between the low sodium and 
liberal sodium diets. Secondary endpoints will include: change in hsCRP, pentraxin3, 
IL6, Lp-PLA2, sCD14, sCD163. We will test the change in biomarkers between the RAAS 
activated (sodium restricted) and RAAS suppressed states (sodium loaded) using the 
paired Student’s t-test for normally distributed variables or Wilcoxon signed-rank test for 
non-normally distributed variables. We will apply Pearson’s correlation for variables that 
are normally distributed and Spearman’s correlation for variables that are non-normally 
distributed to determine whether there is a significant correlation between aldosterone 
during the RAAS activated state and TBR. Covariates considered for inclusion in 
modeling include variables that may affect vascular dysfunction, inflammation, and 
plaque (age, race, sex, BP, tobacco/illicit drug use, family history of CVD, lipids, 
glucose), and HIV parameters (viral load, CD4, duration of HIV and ART use). This will 
permit us to assess relevant factors that may mediate the effect of aldosterone on 
inflammation in HIV and interactions between HIV and traditional risk factors contributing 
to inflammation. Sample Size Determination: Preliminary data in HIV presented in this 

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grant demonstrate a mean change in MCP-1 of 44.0+41.8 pg/mL between a low sodium 
and ad lib sodium diet. Based on this SD, the proposed study, with a sample size of 42 
subjects, and therefore 36 evaluable subjects considering a 15% attrition rate, will attain 
85% power at a two sided α of 0.05 to detect a difference of at least 44.0 pg/mL in mean 
MCP-1 between the formally tested RAAS activated (sodium restricted) and RAAS 
suppressed (sodium loaded) states. For other biomarkers, we have 85% power at a two-
sided 0.05 α level to show a change of at least 0.95 SD between RAAS activated and 
suppressed states. 
 
Aim V: For this aim, the endpoint is change in TBR assessed by cardiac 18F-FDG-
PET/CT. Secondary endpoints include: change in hsCRP, pentraxin3, IL6, Lp-PLA2, 
MCP-1, sCD14, sCD163. Statistical algorithms as detailed in Aim I will be applied to 
these specific endpoints. Similar to Aim I, changes in TBR and inflammatory biomarkers 
over 12 mos comparing eplerenone vs. placebo will be assessed using ITT and 
longitudinal linear effects modeling with imputation and sensitivity analyses. We will also 
determine whether longitudinal changes in arterial inflammation are associated with 
changes in biomarkers of inflammation and immune activation to understand the 
potential relationship of these inflammatory indices as markers of improved indices of 
the coronary vasculature in response to MR blockade in the HIV. Sample Size 
Determination: In our prior studies assessing arterial inflammation on 18F-FDG PET, the 
mean±SD (95% CI) TBR at baseline among HIV subjects was 2.23 ± 0.45 (2.07, 
2.40)mm3.74 In order to estimate the SD of change in TBR, we assumed the intrasubject 
longitudinal correlation over time r=0.75, which results in a conservative SD estimate of 
0.34.This study enrolling 42 subjects with 36 evaluable subjects will attain 85% power at 
a two sided α of 0.05 to detect a difference in mean TBR changes of 0.32 between 
eplerenone vs. placebo, a clinically relevant difference in the changes as our preliminary 
data show that non-HIV subjects have a mean TBR 1.89. For biomarkers, this study has 
85% power at a two-sided 0.05 α level to show a mean change of at least 0.95 SD after 
treatment with eplerenone vs. placebo. 
 
Aim VI: In an exploratory analysis, subjects will be enrolled using a factorial sampling 
strategy into 4 analytic strata (low VAT/absence of plaque, low VAT/presence of plaque, 
high VAT/absence of plaque, high VAT/presence of plaque). Using this design, we will 
first analyze whether there are differences in markers of inflammation and heart disease 
by VAT status (main effects model comparing presence and absence of excess VAT) 
using student’s t-test for variables that are normally distributed or Wilcoxon rank sum 
test for variables that are not normally distributed. Based on the exclusion criteria excess 
VAT is determined to be >110cm2.  After assessing for differences in VAT in the main 
effects model, we will examine the degree to which markers of inflammation and heart 
disease are related to coronary plaque in both the high and low VAT groups, and 
whether this relationship is stronger in the coronary plaque group as a result of 
increased VAT using ANOVA for variable that are normally distributed and Kruskal-
Wallis Test for variables that are not normally distributed.  
 
VII.  Risks and Discomforts 
Blood Drawing: The total blood drawn for subjects completing the study is equivalent to 
approximately 560 ml (over a period of 12 months). This quantity of blood drawing does 
not pose excessive risk to subjects. By comparison, the Red Cross allows a healthy 
adult to donate 1 pint of blood every 8 weeks, which is about 473 ml.  Subjects with a 
hemoglobin < 10 mg/dL will be excluded from the study. There will be minimal risk and 

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discomfort associated with blood drawing and IV placement. The risks of these 
procedures are minor bruising or bleeding at the site of the blood draw or IV catheter or 
feeling faint. Standard clean insertion techniques will be utilized to minimize risk of 
infection.  
 
Intravenous Catheter Placement: There are minor risks and discomforts associated 
with having an intravenous line and with injection of contrast agent through the 
intravenous line, including the possibility of bleeding, pain, inflammation (redness and 
swelling), and leaking of contrast agent outside of the vein at the site of the IV.  These 
problems usually self-resolve or only require minor treatments, such as application of an 
ice-pack or slight pressure for a few minutes. 
 
CT Abdomen: This study is obtained once during the screening process to evaluate for 
visceral adipose tissue area. The radiation risk associated with the single slice CT scan 
of the abdomen is approximately 0.55 mSv. This is equivalent to the amount of radiation 
an individual would normally get in 2 months from natural background sources from the 
earth and the sky. As with the other imaging studies, there may be incidental findings on 
the CT study. If any of these findings are clinically significant, the subjects will be 
withdrawn from the study and referred to the primary care physician for further 
evaluation.  
 
Coronary CTA and Radiation: With the implementation of measures to limit radiation 
exposure, the total dose of the coronary CTA examination will be approximately 4 mSv, 
depending on the weight, gender and heart rate. The added radiation from the two CTA 
scans (screening and follow-up) will be 8 mSv. This is equivalent to the amount of 
radiation an individual would normally get in 2 years and 7 months from natural 
background sources from the earth and the sky.  State-of-the-art dose reduction 
techniques at MGH allow the dose to be substantially lower than historically reported 
median coronary CTA doses. Iterative image reconstruction algorithms allow for further 
reductions in radiation dose. These techniques allow for up to a 50% reduction in 
radiation dose compared with previous generation protocols. Massachusetts General 
Hospital was the first hospital in New England to use the Siemens Definition Flash 
second-generation dual-source 128 or Siemens SOMATOM Force dual-source 196 
detector-row CT, an advanced cardiac-capable CT scanner which allows ultra-fast 
cardiac imaging at the lowest possible radiation doses potentially equivalent to or less 
than a chest CT scan. HIV patients may have clinically significant subclinical CAD. We 
will assess the first coronary CTA for this condition. Any subject with evidence of severe 
coronary artery stenosis, defined as ≥50% stenosis in the left main coronary artery or 
>70% stenosis in the other major coronary arteries will be withdrawn from the study prior 
to further evaluative imaging and procedures and prior to randomization to study drug. 
Subjects with evidence of clinically significant atherosclerosis will be referred to a 
cardiologist for appropriate evaluation and treatment.  
 
CTA contrast medium: CTA requires the intravenous administration of iodinated 
contrast medium. These contrast media have been known to cause renal failure, 
particularly in subjects with a pre-existing renal impairment. Adequate hydration will also 
be emphasized to each study participant. The contrast dose in coronary CTA has 
decreased with the introduction of faster scanners. The dose required will be between 60 
to 100 ml. Allergic reactions to iodinated contrast media may cause skin reactions or in 
very rare occasions result in breathing difficulty and hypotension. Subjects will be closely 

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monitored for the development of any allergic reactions. To minimize risk from iodinated 
contrast, subjects with previous allergic reactions to iodine-containing contrast media or 
signs of renal failure or history of renal disease will be excluded from the CTA study. 
Additional safety criteria will be implemented by measuring serum creatinine and 
excluding subjects with serum creatinine >1.5 mg/ml or estimated GFR<60 
mL/min/1.73m2. Metformin use is an exclusion criteria for the study, so the risk of lactic 
acidosis will be avoided.  
 
Nitroglycerin: Nitroglycerin is commonly used in subjects with angina pectoris and is 
generally considered safe. The side effects and risks of nitroglycerin are generally mild 
and of short duration and include hypotension, tachyarrhythmia, headache, 
lightheadedness, and visual disturbance. Subjects who are on sildenafil, tadalafil, or 
vardenafil (PDE5 inhibitor) will need to stop these drugs at least 5 days prior to receiving 
nitroglycerin on the day of the coronary CTA scan. If baseline systolic blood pressure is 
below 90, nitroglycerin will not be given. If a participant’s blood pressure were to drop 
precipitously or if the participant develops symptoms, standard clinical care will be 
provided. Other contraindications to nitroglycerin include severe aortic stenosis or 
hypertrophic obstructive cardiomyopathy.  
 
Cardiac PET and Radiation: The two cardiac PET scans will involve exposure to 
radiation for research purposes. Subjects will receive a research related rest and stress 
13N-ammonia PET scan before and after a mineralocorticoid receptor antagonist. 13N-
ammonia (20 mCi) will be injected twice prior to rest and stress scans. Each PET scan 
will expose subjects to 3.36 mSv of radiation. The added radiation from the two PET 
scans (baseline and follow-up) will be 6.72 mSv. This is equivalent to the amount of 
radiation an individual would normally get in 2 years and 2 months from natural 
background sources from the earth and the sky. The radioactive tracer will be 
administered at baseline and at 12 months. HIV patients may have silent ischemia. We 
will assess the first regadenoson/adenosine-stimulated coronary blood flow study for this 
condition. Any subject with evidence of clinical significant ischemia will be withdrawn 
from the study prior to further evaluative studies and prior to randomization to study 
drugs. Subjects with evidence of ischemia will be referred to a cardiologist for 
appropriate evaluation and treatment. In addition, there may be incidental findings on the 
PET study. If any of these findings are clinically significant, the subjects will be 
withdrawn from the study and referred to the primary care physician for further 
evaluation.  
 
Regadenoson/Adenosine: Regadenoson or adenosine will be administered during the 
cardiac PET and MRI studies. Regadenoson stress and adenosine stress have been 
used routinely for many years for evaluating patients with known or suspected CAD. 
Regadenoson and/or adenosine will be administered at the radiologist’s discretion. The 
most common side effects associated with the Regadenoson or adenosine infusion 
include: flushing, chest pain/pressure, shortness of breath, palpitations, headache, mild 
hypotension and heart block. These side effects are usually mild and self-limiting. If they 
are severe in intensity, aminophylline IV (1 mg/kg) will be given as per standard protocol. 
Subjects will have their blood pressure and heart rate monitored closely by a physician 
and/or nurse in attendance at all times. The protocol will be immediately discontinued if 
clinically significant atrial or ventricular arrhythmias are observed.  
 

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Radiation Exposure: The total estimated radiation exposure from Aims 1 and 3 is 
approximately 15.27 mSv. Aim 2 has no specific radiation associated. This is 
equivalent to the amount of radiation an individual would normally get in 4 years and 
11 months from natural background sources from the earth and the sky. To minimize 
radiation exposure, coronary CTA dose reduction techniques including ECG-triggered 
tube modulation and automatic exposure control will be applied when possible. Larger 
patients can get higher doses (up to twice that of an average size patient) from any CT 
exam compared to the mean dose. If a patient has received previous radiation 
exposure prior to participation in the study, we will also calculate the total radiation 
exposure and if prior cumulative exposure during the 12 months prior to the study 
exceeds 15 mSv (which is 30% of the maximum recommended annual dose for 
research subjects set by the MGH Radiation Safety Committee), then the subject will 
be excluded from participating. Pregnancy test will be performed prior to CT or PET 
scanning in women. (See also sections for coronary CTA and cardiac PET above for 
specific radiation exposure.)  
 
Abdominal MRI and Cardiac MRI: Subjects will be carefully screened for metal 
implants such as surgical clips or pacemakers prior to MRI scanning. Sources of 
discomfort during the MRI study may include noise and possible claustrophobia. 
Subjects will be given earplugs due to the loud noises during the test.  Subjects who feel 
uncomfortable in confined spaces may have difficulty in the narrow cylinder of the MRI, 
and the MRI can be stopped at any time at the subject’s request. There are no known 
hazards for pregnant women; however, pregnancy is an exclusion for this study. The 
MRI has the potential, during normal routine use, to cause localized warming of the skin 
and the underlying tissues. If the subject experiences discomfort due to warming, the 
procedure will be stopped. Radio-frequency power deposition is strictly controlled by the 
scanner software, in conformance with the applicable FDA guidelines, and cannot be 
overridden by the user. An IV line, placed just prior to the MRI exam, may cause 
tenderness, swelling, warmth at the injection site, and rarely infection. There is no 
radiation exposure other than exposure to the magnetic and non-ionizing radio-
frequency fields, which meet FDA guidelines. All pulse sequences used for this study 
have been approved by the hardware vendor for cardiac MRI studies, and received FDA 
clearance, except for the sequence that is used for perfusion imaging, which is a “works-
in-progress” package that has undergone safety testing by Siemens Medical Systems, 
and been licensed for use to Brigham and Women’s Hospital. A single axial slice of the 
abdomen will be obtained with MRI. The total amount of time in the magnet will be 
approximately 45 min. For the cardiac MRI, the total amount of time in the magnet will be 
approximately 80 min. In addition, there may be incidental findings on the MRI study. If 
any of these findings are clinically significant, the subjects will be withdrawn from the 
study and referred to the primary care physician for further evaluation.  
 
Gadolinium Contrast: Gadolinium contrast has been widely used and is very well 
tolerated. Gadolinium will be administered with the cardiac MRI studies. No contrast is 
administered with the abdomen MRI. The most common adverse reactions of gadolinium 
are transient headache (3.6%), injection site coldness (3.6%), and nausea (1.5%).  
There is a very rare occurrence of nephrogenic systemic fibrosis after gadolinium, but 
this has only been reported in subjects with impaired renal function.  All subjects will 
have a serum creatinine assessed prior to each MRI and subjects with serum creatinine 
>1.5 mg/ml or estimated GFR<60 will be excluded from the study. For this study a 
macrocyclic Gd-contrast agent will be used (Gadoterate meglumine, DOTAREM, 

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Guerbet) which has the highest thermodynamic stability constant among all available 
gadolinium-bound contrast agents to reduce the chance of any exposure to Gd3+ ions. 
 
Incidental Findings: Incidental non-coronary and coronary findings may be obtained, 
and significant non-coronary and coronary findings will be communicated to the subject 
and provider as appropriate.  
 
Standardized High Sodium Diet: Select subjects will be receive broth packets for 3 
days. Increases in dietary sodium may cause mild elevations in blood pressure, but 
usually only by a small amount depending upon the subjects’ salt-sensitivity status. 
Blood pressure will be monitored frequently during study visits. Procedures will not be 
initiated if the subject’s blood pressure is too high or symptoms are present. When 
subjects resume their usual home diets, blood pressure is expected to return to baseline.  
 
Medications: Administration of all medications will be conducted by the appropriate 
health care professional. A physician will be available on-call 24 hours/day, 7 days/week, 
to all study participants for any questions or concerns.  
 
Eplerenone: The eplerenone dose of 50mg daily has been used safely in previous 
studies to improve coronary circulation in individuals with Type 2 diabetes and by others 
in numerous studies of patients with CVD. This dose is FDA approved for indefinite use 
in patients with hypertension or left-ventricular dysfunction following myocardial 
infarction. Hyperkalemia is a potential side effect of eplerenone use, and any subject 
with serum K > 5.5 mEq/L at screen will be excluded. During the study, a subject who 
has an elevated K of > 5.5 mEq/L at any study visit will have a recheck; if the K remains 
elevated after recheck, the dose will be decreased to 50mg daily. If the K remains 
elevated> 5.5 mEq/L, the subject will be excluded from the study.  Additionally, subjects 
who experience symptoms of hyperkalemia and have a K > 5.0 mEq/L will be excluded 
from continued participation in the study.  Subjects who have hypotension (SBP<90 
mmHg) at any study visit after titration to full dose eplerenone 50mg twice daily will be 
given a dose reduction to 50 mg daily. If a subject remains hypotensive (SBP <90 
mmHg) or symptomatic of hypotension at the reduced dose they will be dropped from 
the study.  Since subjects with renal insufficiency may require reduced dosing based on 
creatinine clearance, subjects with serum creatinine > 1.5 mg/dl will also be excluded.  
Other rare side effects include dizziness, fatigue, and diarrhea; these will be assessed 
for throughout the study. The effect of eplerenone on an embryo, fetus, or on a 
breastfeeding infant, is unknown and may be harmful.  Because of these unknown risks, 
women cannot take part in this study if they are: pregnant, trying to become pregnant, 
breastfeeding. If women become pregnant or think they are pregnant during the study, 
they must stop taking the study medication and will be withdrawn from the study.  We 
have received FDA IND exemption for the use of eplerenone in HIV for insulin resistance 
and recently received an FDA IND exemption for application in CVD indices in HIV. 
Protease inhibitors with the most significant effect on CYP3A4 will be exclusionary as in 
our prior trials of HIV patients. We will also exclude subjects using other strong inhibitors 
of CYP3A4, as well as CYP3A4 inducers. Furthermore, all subjects will be carefully 
monitored for side effects, including frequent potassium and BP monitoring. A 50mg 
twice daily dose of eplerenone has been chosen, such that even if concentrations do 
increase somewhat through pharmacokinetic interactions, we expect the drug to be well 
tolerated. The dose of 100 mg/day has been effective in numerous studies of non-HIV 
patients and is expected to be effective in the proposed studies.  

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Optional Substudy--Cardiac 2-deoxy-2-18F-Fluorodeoxyglucose Positron 
Emission Tomography/Computed Tomography (18F-FDG-PET/CT) and Radiation: 
The two cardiac PET/CT scans will involve exposure to radiation for research purposes. 
Subjects will receive a scan before and after a mineralocorticoid receptor antagonist. For 
18F-FDG-PET/CT, the administered dose from 18F- FDG for a typical cardiac study is 370 
MBq (10 mCi=7.03 mSv) and the effective dose for an attenuation correction scan of 
head/neck/chest/upper abdomen is about 1.58 mSv. The total effective dose from two 
FDG-PET/CT studies would be 17.22 mSv. This is equivalent to the amount of radiation 
an individual would normally get in 5 years and 7 months from natural background 
sources from the earth and the sky. A STAT serum pregnancy test will be performed on 
the day of prior to commencement of the study. In addition, there may be incidental 
findings on the PET study. If any of these findings are clinically significant, subjects will 
be informed, referred to their primary care physician for further evaluation, and 
withdrawn as appropriate from the study. 
 
Optional Substudy--Radiation Exposure The total estimated radiation exposure for 
the entire study (main study+substudy) would be 32.49 mSv. This is equivalent to the 
amount of radiation an individual would normally get in 10 years and 6 months from 
natural background sources from the earth and the sky. (See also sections radiation 
exposure for other precautions and cardiac 18F-FDG-PET/CT above for specific radiation 
exposure related to the substudy.) 
 
Optional Substudy--Blood draw The total amount of blood drawn for the substudy will 
be approximately 4 mL over 1 year for females only. This will be a minimal amount 
added to the main study. The total blood drawn for subjects completing the entire study 
(main study+substudy) is equivalent to approximately 564ml (over a period of 12 
months).  
 
Optional Blood Sampling Visit (for those that do not qualify after completion of 
both screening visits)--Blood draw The total amount of blood drawn for the Optional 
Blood Sampling Visit will be approximately 48 ml. This will be a minimal amount added 
to the screening visits. The total blood drawn for subjects completing this optional visit 
(screening visits+optional visit) is equivalent to approximately 73 ml.  
 
 
VIII.  Potential Benefits 
There are no direct benefits related to participation in the study, but subjects will receive 
regular physical exams with blood pressure monitoring, lifestyle counseling to improve 
nutrition and physical activity, and screen testing that will evaluate for clinically 
significant coronary artery disease. There may be potential improvements in CVD and 
inflammation as a result of treatment with eplerenone and/or lifestyle modification.  In 
addition, all subjects will be provided with tools to help them meet the prescribed goals, 
including a core curriculum binder. Clinically interpretable information on metabolic 
parameters will be provided to the subject and may help subjects and their clinicians to 
better understand their metabolic risk if they choose to obtain such information. Any 
abnormal testing will be conveyed to the subjects’ primary care physicians with their 
permission. In addition, information obtained from this study will benefit HIV patients in 
the future. Therefore, the benefits of this study are felt to outweigh its risks described 
above. 
 

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For those who do not qualify and choose to participate in the optional blood sampling 
visit, there are no direct benefits, but subjects will receive screen tests that will evaluate 
clinically for visceral fat and coronary artery plaque and inform their medical history. In 
addition, information obtained from the stored blood will benefit HIV patients in the 
future. Therefore, the benefits of this study are felt to outweigh its risks described above. 
 
IX.  Monitoring and Quality Assurance 
Written informed consent for this protocol will be obtained from all subjects at the first 
screening visit, prior to any procedures or interventions. In all cases, consent will be 
witnessed by an appropriate health care professional (investigator/co-investigator staff).  
All efforts will be made to insure the privacy rights of the subject. No written or oral 
communication will be made about any subject with anyone other than the subject, 
unless the subject so requests. Medical information obtained from the study may 
become part of the subject’s permanent hospital record, subject to the confidentiality and 
privacy regulations of the Massachusetts General Hospital. Subjects will be closely 
monitored to ensure that study participation is not adversely affecting their quality of life, 
and any adverse events will be reported in a timely fashion and in accordance with the 
Partners HRC guidelines for adverse event reporting. PHRC requires the reporting of 
unanticipated problems, including risks, within 5 working days or 7 calendar days. 
Kidney function and potassium levels will be serially monitored. If a subject experiences 
an opportunistic infection or any acute illness, the lifestyle modification program will be 
held while the subject is acutely ill.   
 
Hyperkalemia is a potential side effect of eplerenone use, and contraindications for the 
use of eplerenone include serum K > 5.5 mEq/L at initiation.  Therefore, any subject with 
serum K >5.5 mEq/L at screen will be excluded from the study. During the study, a 
subject who has an elevated K of > 5.5 mEq/L at any study visit will have a recheck; if 
the K remains elevated after recheck they will be excluded from the study.  Additionally, 
subjects who experience symptoms of hyperkalemia and have a K > 5.0 mEq/L will be 
excluded from continued participation.  Subjects who have symptomatic hypotension at 
any study visit after titration to full dose eplerenone 50mg twice daily will be given a dose 
reduction to 50 mg daily. Since patients with renal insufficiency may require reduced 
dosing based on creatinine clearance, subjects with renal insufficiency (serum creatinine 
> 1.5 mg/dl) will also be excluded from participation.  Other side effects have been 
reported and include dizziness, fatigue, diarrhea, headache, stomach pain, cough, 
breast enlargement or breast enlargement, rash, abnormal vaginal bleeding.  Rare but 
serious side effects include chest pain, tingling in arms and legs, loss of muscle tone, 
weakness or heaviness in legs, confusion, lack of energy, cold, gray skin or irregular 
heartbeat.  These potential side effects will be assessed for throughout the study. 
Exclusion criteria during the study include initiation of ACE-I, ARB, or spironolactone; 
Hgb < 10; ALT >3.0x ULN; persistent hyperkalemia (K >5.5 mEq/L despite recheck 
and/or symptoms of hyperkalemia if K >5.0 mEq/L). If a subject remains hypotensive 
(SBP <90 mmHg) or symptomatic of hypotension after a dose reduction of eplerenone to 
50 mg for this same reason during the study, they will be dropped from the study. 
 
Data Safety Monitoring Plan 
Prior to the start of study, a data safety monitoring board will be created and this board 
will consist of a statistician, a clinician not directly related to the research project, but one 
who is familiar with HIV infection and its complications, and a member of the HIV 
community.  This board will meet quarterly to review any potential side effects or 
adverse events in relation to the use of eplerenone or participation in the study. The 

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DSMB will meet and review adverse events in accordance with the guidelines of the 
Massachusetts General Hospital Human Research Committee. Reports generated by 
the DSMB will be submitted to the Partners Institutional Review Board after when 
otherwise indicated or requested. 
The principal investigator and/or co-investigator will be responsible for following patients 
during the study. Patients will be assessed at every visit during their study participation.  
The investigators and study staff will assure that all CRFs, source documents and 
informed consent are accurate and complete after each study visit. 
The data from these studies are stored in a password protected file with access only to 
study staff and those interpreting the studies. All data are securely stored and only 
accessible to co-investigators and study staff in order to protect confidentiality. 
 
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Appendix A 
 
Strong Inhibitors of CYP3A4 
• 
Ketoconazole 
• 
Itraconazole 
• 
Fluconazole 
• 
Ritonavir 
• 
Nelfinavir 
• 
Indinavir 
• 
Clarithromycin 
• 
Telithromycin  
• 
Erythromycin 
• 
Nefazadone 
• 
Bergamottin (in grapefruit juice) 
• 
Quercetin (nutritional supplement) 
• 
Aprepitant 
• 
Verapamil 
• 
Chloramphenicol 
• 
Saquinavir