Clinical trial NCT02253394
Conditions: Pulmonary Arterial Hypertension
Keywords: Pulmonary Arterial Hypertension (PAH) Ambrisentan Spironolactone Selective Endothelin A (ETA) inhibition Aldosterone antagonism Cardiac output (CO) Right ventricular (RV) function Heart failure Quality of life Pro-inflammatory cytokine Interleukin-6 (IL-6) Troponin-I N-terminal pro-brain natriuretic peptide (NT-BNP) Collagen metabolism N-terminal procollagen type I Collagen III Echocardiography WHO Functional Class Cardiopulmonary Exercise Test with Innocor Peak oxygen consumption (pVO2) Liver function markers (AST/ALT) Renal function markers (creatinine and potassium)
Sponsor: Brigham and Women's Hospital
Start date: 2015-09-01; Completion date: 2018-02-01
Enrollment: 2 participants; Allocation: RANDOMIZED; Intervention model: CROSSOVER

Brief summary:
The purpose of this study is to find out if spironolactone added to ambrisentan for Pulmonary Arterial Hypertension (PAH) will increase exercise capacity. We also want to find out if spironolactone and ambrisentan effect the cardiac output (amount of blood the heart pumps every minute), right ventricle function and quality of life.

Detailed description:
A prospective, double blind, placebo-controlled clinical study involving 30 patients with World Health Organization (WHO) Group 1 pulmonary arterial hypertension being treated with ambrisentan randomized to receive placebo or spironolactone (50 mg/d) for 90 days using a cross-over trial design.

Eligible participants will be randomized to receive placebo or spironolactone (50 mg/d) for 90 days (Phase I). At the completion of Phase I, participants will undergo repeat end-point assessment followed by a 21-day drug washout period. Then, the 90 day crossover phase of the trial will occur (Phase II), in which participants randomized to placebo in Phase I will be treated with spironolactone (50 mg/d) in Phase II and vice versa. At the conclusion of Phase II, end-point measures are reassessed.

Spironolactone is a diuretic used in treatment of PAH patients. Spironolactone is usually added to medical treatment when doses of Lasix/Torsemide are increased and patients are at risk for hypokalemia.

Study procedures being done for this research study are the standard procedures performed on all PAH patients when they are in clinic for follow-up except for the Cardiopulmonary Exercise Test (CPET) with Innocor.

Arms: arm 1: Ambrisentan 5 or 10 mg every day (QD) Spironolactone 50 mg QD arm 2: Placebo mimics spironolactone 50 mg and will be taken QD
Interventions: intervention 1: Ambrisentan plus Spironolactone intervention 2: Ambrisentan plus Placebo
Intervention descriptions: intervention 1: Cardiopulmonary fitness intervention 2: Placebo is a sugar pill manufactured to resemble spironolactone 50 mg Cardiopulmonary fitness

Protocol documents:
Prot_SAP_000.pdf: 
Amendment 4 24-Aug-2016 
PROTOCOL CAPS-PAH 
Page | 1 
 
 
 
 
 
 
08/14/2019 
 
Re: The Combination Ambrisentan Plus Spironolactone in Pulmonary Arterial Hypertension Study (The CAPS-PAH Study) 
 
NCT02253394 
 
The study only had two subjects enrolled, so there are no results to this study. The study was closed February 2018. 
Sincerely, 
Laurie Lawler, RN 
Research Nurse 
Brigham and Women’s Hospital 
Pulmonary Vascular Disease Service 
75 Francis Street, PBB-Clinics 3 
Boston, MA 02115 
Phone: 617-525-9731 
Fax: 617-264-6873 


Amendment 4 24-Aug-2016 
PROTOCOL CAPS-PAH 
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The Combination Ambrisentan Plus Spironolactone in 
Pulmonary Arterial Hypertension Study (The CAPS-PAH Study) 
Protocol CAPS-PAH 
Principal Investigator: 
Bradley A. Maron, MD 
 
 
 
Participating Centers & Investigators: 
Brigham and Women’s Hospital, Boston, MA – Aaron Waxman, M.D., Ph.D. 
Tufts Medical Center, Boston, MA – 
. 
Boston Medical Center, Boston, MA – 
. 
 
Original Protocol Date: 29-Oct-2014 
Amendment 1 Date: 27-Jan-2015 
Amendment 2 Date: 23-Feb-2016 
Amendment 3 Date: 05-Jul-2016 
Amendment 4 Date: 24-Aug-2016 


Amendment 4 24-Aug-2016 
PROTOCOL CAPS-PAH 
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INVESTIGATOR’S AGREEMENT 
I have read the attached protocol entitled “The Combination Ambrisentan Plus Spironolactone in Pulmonary Arterial 
Hypertension Study (The CAPS-PAH Study),” Amendment 2 dated 23-Feb-2016, and agree to abide by all provisions set 
forth therein. 
I agree to comply with the International Conference on Harmonisation (ICH) Guideline for Good Clinical Practice and 
applicable Food and Drug Administration regulations/guidelines set forth in 21 Code of Federal Regulations Parts 50, 54, 
56 and 312 and local regulations. 
I agree to ensure that the confidential information contained in this document will not be used for any purpose other than 
the evaluation or conduct of the clinical investigation. 
This protocol has been received for information only and must not be implemented before all necessary regulatory agency 
and ethics approval documents have been obtained. 
 
 
 
Signature of Principal Investigator 
Date 
 
 
 
 
 
 
Printed Name of Principal Investigator 


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PROTOCOL CAPS-PAH 
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I. Background and Significance 
Pulmonary Arterial Hypertension (PAH). PAH is a life-threatening disease characterized by a progressive pulmonary 
vasculopathy with ensuing right heart failure if left untreated. Patients usually present late in the course of the disease with 
nonspecific symptoms (fatigue, breathlessness, syncope), which are common to many other disease states, making the 
diagnosis difficult. PAH may arise within the context of various diseases; the heterogeneous range of PAH-associated 
etiologies complicates further the clinical framework of this highly morbid disease. 
PAH is characterized by a progressive increase in pulmonary vascular resistance (PVR) and pulmonary arterial pressure 
(PAP) leading to right heart failure, and is associated with significant morbidity and mortality.6,7 PAH is hemodynamically 
defined as a resting mean PAP ≥ 25 millimeter of mercury (mmHg), with a pulmonary capillary wedge pressure (PCWP) ≤ 
15 mmHg and PVR > 3 Wood units (> 240 dyn·sec·cm-5).6,7 
The PAH pathophenotype is generally classified into five groups according to pathological, pathophysiological, and 
therapeutic characteristics. Despite comparable elevations of PAP and PVR in the different clinical groups, the underlying 
mechanisms, the diagnostic approaches, and the prognostic and therapeutic implications are completely different. 2 PAH 
may occur in the absence of a demonstrable cause (idiopathic or familial),3 or as a complication of congenital cardiac 
shunts, 3 connective tissue disease, particularly scleroderma,3,4 human immunodeficiency virus (HIV) infection,5 sickle-cell 
disease, chronic liver disease, anorexigens use, 3,4 obstructive or restrictive lung disease,3,4 thromboembolic disease, or 
sarcoidosis. The pathology of pulmonary hypertension involves multiple pathways including vasoconstriction, vascular 
remodeling of the pulmonary vessel wall caused by extensive cell proliferation, and thrombosis. Evidence demonstrates 
that inflammatory processes also play a significant role in the various types of PAH.3,4 
Elevated levels of the mineralocorticoid hormone aldosterone promote a pulmonary vasculopathy that is due, in part, to 
increased reactive oxygen species generation in pulmonary artery endothelial cells.6.7 This impairs endothelin type-B 
(ETB)-dependent synthesis of the potent vasodilator and anti-mitogenic molecule nitric oxide (NO). In cultured pulmonary 
artery endothelial cells, inhibition of aldosterone with spironolactone, a mineralocorticoid receptor antagonist, restores 
ETB-dependent NO synthesis, which is associated with the prevention or reversal of pathological remodeling of distal 


Amendment 4 24-Aug-2016 
PROTOCOL CAPS-PAH 
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pulmonary arterioles and improved cardiopulmonary hemodynamics in experimental animal models of pulmonary arterial 
hypertension (PAH) in vivo.6 
We have demonstrated that in patients with PAH, hyperaldosteronism in the pulmonary circulation correlates positively 
with pulmonary vascular resistance and the transpulmonary gradient, which are hemodynamic measures of pulmonary 
vascular remodeling.4 Moreover, we present novel preliminary data in the current proposal in support of the assertion that 
the endothelin receptor-aldosterone axis is a potentially modifiable contributor to adverse clinical outcome in patients with 
PAH. 
We analyzed retrospectively the Pulmonary Arterial Hypertension, Randomized, Double-Blind, Placebo-Controlled, 
Multicenter, Efficacy Study-1 (ARIES-1) and Study-2 (ARIES-2) trials to demonstrate that concomitant spironolactone and 
ambrisentan (a selective endothelin type-A [ETA] receptor antagonist, 10 mg/d) use is associated with improved 6-minute 
walk distance (6MWD) and biochemical evidence of heart failure, as well as decreased PAH-associated clinical worsening 
compared to ETA therapy alone.8 These observations are in alignment with previously reported findings from our basic 
science laboratory suggesting that combination therapy with spironolactone to prevent deactivation of ETB in pulmonary 
artery endothelial cells with the selective ETA antagonist ambrisentan6 is a potentially effective treatment strategy for PAH 
patients. Despite these observations, prospective randomized clinical trials are required to characterize accurately the 
effect of combination aldosterone and ETA inhibition on clinical outcome in PAH. 
Thus, the hypothesis of the current proposal is that the addition of spironolactone (50 mg/d) to selective ETA inhibition 
(standard therapy) with ambrisentan (5-10 mg/d) is more effective than standard therapy alone at improving 
cardiopulmonary fitness and quality of life in patients with PAH. 
Recent clinical trial data indicates that the initiation of combination therapy for treatment naïve PAH patients with 
ambrisentan and phosphodiesterase type-V inhibitors (PDE-Vi) (e.g., sildenafil/tadalafil) is superior to monotherapy alone 
for decreasing PAH-related clinical events. It is anticipated that this combination therapy will be incorporated into the 
expert consensus guidelines for the treatment and management of PAH patients. Importantly, aldosterone has been 
evaluated by our group in the context of soluble guanylyl cyclase-nitric oxide signaling, which, in turn, is the target of PDE- 
Vi therapies. In specific, we have demonstrated that aldosterone increases vascular oxidant stress levels to inhibit soluble 
guanylyl cyclase sensing by nitric oxide to diminish blood relaxation (Maron; Leopold). Therefore, it is anticipated that 
aldosterone inhibition with spironolactone will provide a synergistic mechanism with PDE-Vi by which to improve 
pulmonary vascular tone in patients with PAH. 


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PROTOCOL CAPS-PAH 
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II. Specific Aims 
Specific Aim 1: Study the effect of combination ambrisentan (5-10 mg/d) + spironolactone (50 mg/d) on cardiopulmonary fitness as 
assessed by change from baseline (study drug day 1) at study drug day 90 for each of the two trial phases (See Section IV) on the 
following dimensions: (i) 6 minute walk distance and (ii) peak oxygen consumption (ml/kg/min)(pVO2) at the completion of exercise. 
Hypothesis: Improvements to pulmonary vascular remodeling and function mediated by selective ETA inhibition plus aldosterone 
antagonism will influence favorably pulmonary vascular-right ventricular performance to enhance cardiopulmonary fitness and 
improve exercise tolerance. 
Specific Aim 2: Study the effect of combination ambrisentan (5-10 mg/d) + spironolactone (50 mg/d) on cardiac output, right 
ventricular (RV) function, key biochemical measures of heart failure, and quality of life. 
Hypothesis: The favorable effects of combination ambrisentan + spironolactone therapy on cardiopulmonary function will associate 
positively to improvements in RV function, biochemical measures of heart failure and fibrosis, and self-reported quality of life 
compared to standard therapy alone. 
• 
Change from baseline (study drug day 1) at study drug day 90 for each of the two trial phases in levels of the pro- 
inflammatory cytokine IL-6, as well as troponin-I and N-terminal pro-brain natriuretic peptide (NT-BNP), which are validated 
biochemical measures of right ventricular stress and right heart failure in patients with PAH, respectively, will be assessed. 
• 
Change from baseline (study drug day 1) at study drug day 90 for each of the two trial phases in right ventricular 
geometry/function by echocardiography will be assessed. 
• 
To assess the possibility that spironolactone modulates clinical effects in PAH by influencing levels of cardiac and pulmonary 
vascular fibrosis, change from baseline (study drug day 1) at study drug day 90 for each of the two trial phases in the 
circulating levels of N-terminal procollagen type I and collagen III, which are bona fide markers of collagen metabolism (i.e., 
fibrosis), will be measured.9 
• 
The SF-36 quality of life scale will be used to assess changes in quality of life from baseline (study drug day 1) at study drug 
day 90 for each of the two trial phases. 


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PROTOCOL CAPS-PAH 
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III. Subject Selection 
The study population involves patients with Group I Pulmonary Arterial Hypertension. Subjects will be recruited from all 3 
participating centers. 
Inclusion Criteria 
1. Voluntarily gives informed consent to participate in the study. 
2. Right heart catheterization demonstrating conventional mean pulmonary artery pressure (mPAP) >25, pulmonary 
vascular resistance (PVR) >3.0 Wood Units, pulmonary capillary wedge pressure (PCWP) <16 mmHg within two 
years of enrollment 
3. Subject is 16–75 years of age (inclusive) at Screening. 
4. Diagnosis of symptomatic idiopathic or heritable PAH, PAH associated with CTD, PAH associated with 
repaired/unrepaired congenital systemic-to-pulmonary shunt, Portopulmonary hypertension or PAH associated with 
HIV infection. 
5. New York Heart Association Functional Class II or III 
6. Combination therapy: Stable therapy with ambrisentan 5 or 10 mg every day for ≥90 days and stable therapy for 
≥90 days with sildenafil or tadalafil at any pulmonary hypertension therapeutic dose 
7. Baseline 6-Minute Walk Distance >50m 
Exclusion Criteria 
1. Substantial Primary Lung disease 
• FEV-1/FVC <0.6 and FEV1 <70% predicted 
• DLCO <30% predicted 
• Pulmonary fibrosis14 
2. Left ventricular ejection fraction < 50% 
3. Pulmonary capillary wedge pressure > 16 mmHg 
4. Aortic valve disease 
5. Ischemic heart disease 


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PROTOCOL CAPS-PAH 
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6. Systemic hypotension (SBP <90 mmHg) 
7. Co-existing treatment with other endothelin receptor antagonists or prostacyclin analogues 
8. New York Heart Association Functional Class IV 
9. Chronic thromboembolic pulmonary hypertension 
10. Known or suspected pulmonary veno-occlusive disease 
11. Serum creatinine >2.0 mg/dL in women, Serum creatinine >2.5 mg/dL in men 
12. Baseline serum potassium >5.0 mEq/L 
13. Participation in ongoing drug/intervention-based clinical trial 
14. Pregnancy 
15. Unable to provide consent 
 
IV. Subject Enrollment 
To test our hypothesis, we propose a prospective, double blind, placebo-controlled clinical study involving 30 patients with 
World Health Organization (WHO) Group 1 pulmonary hypertension randomized to receive placebo or spironolactone (50 
mg/d) for 90 days using a cross-over trial design (Figure 1). 
 
21 d 
<1 d 
90 d 
21 d 
90 d 
Baseline Testing 
  
Placebo 
 
Stage I 
 
 
 
 
Wash-out 
 
 
  
 SPIRO    
 
(50 mg/d) 
Stage II 
Screen 
 
 
 
 
 
Ramdomization 
SPIRO 
(50 mg/d) 
 
 
 
Stage I 
End-point 
Placebo  
 
 
Stage II 
End-point 


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PROTOCOL CAPS-PAH 
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Figure 1. Proposed patient flow strategy for enrollment and follow up in the CAPS-PAH study. SPIRO, spironolactone (50 
mg/d); 6MWT, 6-minute walk test; d, days. 
Participants on a stable dose of ambrisentan (5mg/d – 10 mg/d for >3 mo.) enrolled in this study will undergo baseline 
biochemical, functional, physiological, and clinical testing, which comprises the study end-points. Eligible participants will 
then be randomized to receive placebo or spironolactone (50 mg/d) for 90 days (Phase I). At the completion of Phase I, 
participants will undergo repeat end-point assessment followed by a 21-day drug wash out period. Then, the 90 day 
crossover phase of the trial will occur (Phase II), in which participants randomized to placebo in Phase I will be treated 
with spironolactone (50 mg/d) in Phase II and vice versa. At the conclusion of Phase II, end-point measures are 
reassessed. 
 
V. Study Procedures 
Clinical Assessments 
1. Medical History and Physical Examinations 
A complete medical history, demographics, PAH history, and physical examination (PE) will be conducted during the 
Baseline Visit. Significant past or present illnesses, current prescription or nonprescription medications (including 
vitamins and herbal products), and history of allergies or idiosyncratic responses to drugs will be included. Any 
significant changes to the subject’s medical condition, PE, and concomitant medications must be documented 
throughout the course of the study. A complete PE will be conducted at every clinic visit. 
2. Vital Signs 
Vital signs will be assessed at Baseline prior to starting study medication and then at every clinic visit. Vital signs 
include blood pressure, peripheral (radial/brachial artery) heart rate, respiration rate, and weight. Height will be 
collected at the Baseline visit. 
Weight will be obtained at home every day during participation in the study. Subjects will be instructed to weigh 
themselves every morning and to maintain a diary of daily weights. Diary can be found in Appendix D. 


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PROTOCOL CAPS-PAH 
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3. Six Minute Walk Test 
The intent of the 6MWT is to evaluate exercise capacity associated with carrying out activities of daily living. All 
6MWTs will be conducted by qualified, trained personnel in a designated 6MWT area which meets the requirements 
as described in Appendix A. Prior to the start of each 6MWT the subject should rest (seated) for at least 5 minutes. 
4. Borg Dyspnea Score 
The Borg dyspnea score will be assessed following each 6MWT. The Borg dyspnea score is a 10-point scale rating 
the maximum level of dyspnea experienced during the 6MWT (Appendix A). Scores range from 0 (for the best 
condition) to 10 (for the worst condition). 
5. WHO Functional Classification 
The WHO functional classification for PAH (Appendix B) will be assessed at all Baseline prior to starting study drug 
and at all subsequent scheduled study visits. 
6. Laboratory Testing 
Clinical laboratory tests will be assessed at the Baseline visit prior to starting study drug. Clinical laboratory 
assessments will also be assessed at every clinic visit. Clinical laboratory testing is displayed in Appendix C. 
Total amount of blood collected during the entire study is 120 mL. 
Subjects enrolled at Boston Medical Center and Tufts Medical Center will have research biomarker blood samples 
collected at Brigham and Women’s Hospital at Baseline and Day 90 of Phase I, and Days 1 and 90 of Phase II. The 
research laboratory samples will be collected at BWH when they are here for the Cardiopulmonary 
Exercise Test (CPET) with Innocor. The samples will be collected at BWH because the research 
laboratory testing will be performed in Brad Maron’s laboratory The CPET-Innocor® will be performed 
prior to Baseline Visit for all subjects enrolled at BWH. Subjects enrolled at BMC and Tufts will have 
CPET performed after the consent form is signed, but is a clinically indicated procedure. 
 
Approximately 30 mL of blood will be collected 
7. Echocardiography 


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PROTOCOL CAPS-PAH 
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Echocardiography (ECHO) will be assessed at Baseline and Day 90 of Phase I, and Days 1 and 90 of Phase II. The 
ECHO will evaluate the right ventricle. It is anticipated that by decreasing pulmonary vascular fibrosis to improve 
pulmonary vascular function, improvements to RV loading will associate with favorable changes to cardiac output, and, 
consequently, PAH symptomatology. 
8. Cardiopulmonary Exercise Test with Innocor™ 
A previously standardized cardiopulmonary exercise test graded-exercise (CPET) protocol will be used to assess 
change in non-invasively measured cardiac output and peak oxygen consumption (pVO2) from baseline (study drug 
day 1) at study drug day 90 for each of the two trial phases. Refer to Appendix F for description of CPET. All CPET- 
Innocor required for the protocol will be performed at BWH. 
Functional capacity will be assessed per CPET protocol and change in distance on the 6MWT from baseline (study 
drug day 1) at study drug day 90 for each of the two trial phases. 
9. Adverse Events (AE) 
AEs will be captured from the time the informed consent form is signed. All AEs should be followed until either 
resolution (or return to normal or Baseline values), until they are judged by the Investigator to no longer be clinically 
significant, or for up to 30 days if the AE extends beyond the final visit. All severe AEs (SAEs) should be followed until 
resolution, death, or the subject is lost to follow-up even if they are ongoing more than 30 days after completion of the 
final visit. Appendix E provides the guidelines and definitions for recording AEs. 
Each site will be responsible for completing a MedWatch form for all serious adverse events and faxing or e-mailing to 
the FDA and Laurie Lawler, R.N. for Bradley Maron, M.D. to review. Refer to Appendix E. 
Symptoms of PAH (disease related events) should only be recorded as an AE if the event is either serious, new, or 
unusual with respect to intensity, frequency, duration as compared to symptoms in the subject’s medical history; or 
there is a reasonable possibility that the event was caused by the study drug. 
Inflammatory Biomarker Sub-Study- 
Tufts Medical Center Refer Appendix G 
6 cc of heparinized blood will be collected and plasma will be obtained. 


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Time points: Baseline; End of stage 1; End of stage 2. 
De-identified samples will be stored at local sites and shipped in batches of 6 samples. Samples will be labeled with 
unique subject number date and time of collection. Samples to be shipped to 
at the following address: 
Tufts Medical Center 
800 Washington street 
 
Boston, MA02111 
Tel 617-636-7609 
Tests to be performed from each sample: 
• IL-6 
• IL-6R 
• Gp130 
• IL10 
• TNF-α 
• IL-1β 
• IL-2 
• IFN-ɤ 
To measure cytokines, we will use ELISA assay (simple assay or multiplex assays, Bio-Rad) 


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OVERALL SCHEDULE OF TIMES AND EVENTS (Table 1) 
PHASE I 
Wash Out 
PHASE II 
Days 1 - 90 
Days 91 -111 
Days 112  - 202 
1 
30 days 
prior to 
1st dose 
study drug 
3 
+/- 3 
days 
14 
+/- 3 
days 
28 
+/- 3 
days 
42 
+/- 3 
days 
56 
+/- 3 
days 
70 
+/- 3 
days 
90 
+/- 5 
days 
21 days 
1 
+/- 5 
days 
3 
+/- 3 
days 
14 
+/- 3 
days 
28 
+/- 3 
days 
42 
+/- 3 
days 
56 
+/- 3 
days 
70 
+/- 3 
days 
90 
+/- 5 
days 
Telephone Contact 
X 
X 
X 
X 
X 
X 
X 
X 
Medical History 
X 
Physical Examination (Complex) 
X 
X 
X 
X 
Physical Examination (Simple) 
X 
X 
X 
X 
Assess Medication Compliance 
X 
X 
X 
X 
X 
X 
X 
X 
SF-36 
X 
X 
X 
X 
Other Biochemical Assessment 
Troponin-I 
Collagen III 
N-terminal procollagen type I 
IL-6 
X 
X 
X 
Inflammatory Biomarkers Sub-study /Ioana 
Preston, MD 
IL-6 
IL-6R 
Gp130 
IL10 
TNF-α 
IL-1β 
IL-2 
IFN-ɤ 
X 
X 
X 
NT-BNP 
X 
X 
X 
X 
Renal function markers (Creatinine/K+) 
X 
X 
X 
X 
X 
X 
X 
X 
Liver function markers 
X 
X 
X 
X 
6-MWT/Borg Score 
X 
X 
X 
X 
Echocardiography 
X 
X 
X 
X 
Innocor™ 
X 
X 
X 
X 


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Table 1. Proposed evaluation/diagnostic testing time points post-randomization in the CAPS-PAH study. Liver function 
markers are aminotransferase/alanine aminotransferase; Renal function markers are creatinine and serum potassium; 6-MWT, 6- 
minute walk test; NT-BNP, N-terminal pro-type brain natriuretic peptide; Wash, wash out for 21 days. 
 
 
Baseline Visit (Day 1, Phase I): 
Baseline visit will require a visit to the enrolling center and then a visit to BWH for CPET-Innocor and collection of 
research biomarker blood samples. The visit to BWH needs to be scheduled 24 to 72 hours after the visit at the enrolling 
center. 
Written informed consent must be obtained from the subject. Participation in this study is voluntary. The nature of the 
study will be fully explained to each subject during the informed consent process and the subject will have the opportunity 
to ask questions. An informed consent form will be signed by the subject and the person performing the consent 
discussion, and retained by the Investigator. A copy of the signed informed consent form will be given to the subject. 
Assessments to be performed during visit at local sites: 
• Inclusion/Exclusion criteria. 
• Medical history to include PAH history and PAH treatment history. 
• Physical examination (i.e., jugular venous pressure) and vital signs (blood pressure, heart rate, and respiratory 
rate). Weight and height to be measured. 
• SF-36 questionnaire 
• 6-Minute Walk Test/Borg Score. 
• Laboratory tests: 
1. Liver function markers (AST/ALT) 
2. Renal function markers (creatinine and potassium) 
3. Inflammatory Biomarkers 
• Echocardiography 
• Dispense weight diary 


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Assessments to be performed at BWH: 
• Laboratory tests to be performed at BWH at time of CPET-Innocor. 
1. Troponin-I 
2. Collagen III 
3. N-terminal procollagen type I 
4. IL-6 
5. NT-BNP 
6. Urine pregnancy test for women of child-bearing potential 
• CPET-Innocor™ - Standard of Care. 
• Randomization after all baseline procedures/tests have been completed. To be completed at BWH. 
• Dispense supply of study drug. Study drug will be dispensed to subjects at BWH. 
Telephone Calls: Day 3, Phase I (after initiation of placebo or spironolactone) and then every 2 weeks from Baseline 
(Days 28, 42, and 70, Phase I). Telephone calls will not occur on days of clinic visits. 
• Telephone call to monitor compliance, AEs, use of concomitant medications and weight 
Days 14 and 56, Phase I assessments are listed below: 
• Physical exam and vital signs (blood pressure, heart rate, and respiratory rate). Weight to be measured. 
• Laboratory tests: 
1. Renal function markers (creatinine and potassium) 
• Assess medication compliance 
• Collect and review weight diary and dispense new weight diary 
Day 90, Phase I: 
Day 90 Phase I visit will require a visit to the enrolling center and then a visit to BWH for CPET-Innocor and collection of 
research biomarker blood samples. The visit to BWH needs to be scheduled 24 to 72 hours after the visit at the enrolling 
center. 
Assessments to be performed during visit at local sites: 


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• Physical exam and vital signs (blood pressure, heart rate, and respiratory rate). Weight and height to be measured. 
• SF-36 questionnaire 
• 6-Minute Walk Test/Borg Score 
• Laboratory tests: 
1. Liver function markers (AST/ALT) 
2. Renal function markers (creatinine and potassium) 
3. Inflammatory Biomarkers 
• Collect and review weight diary and dispense new weight diary 
• Echocardiography 
• Collect and review weight diary and dispense new weight diary 
Assessments to be performed at BWH: 
• Laboratory tests to be performed at BWH at time of CPET-Innocor. 
1. Troponin-I 
2. Collagen III 
3. N-terminal procollagen type I 
4. IL-6 
5. NT-BNP 
6. Urine pregnancy test for women of child-bearing potential 
• 
CPET-Innocor™ 
• Assess medication compliance 
• Collect all study drug and study drug containers 
Wash Out Period (21 days): 
Subjects will be asked to obtain a morning weight everyday and to keep a log of their weight. 
Day 1, Phase II assessments are listed below: 
Day 1 Phase II visit will require a visit to the enrolling center and then a visit to BWH for CPET-Innocor and collection of 
research biomarker blood samples. The visit to BWH needs to be scheduled 24 to 72 hours after the visit at the enrolling 
center. 


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Assessments to be performed during visit at local sites: 
• Physical exam and vital signs (blood pressure, heart rate, and respiratory rate). Weight and height to be measured. 
• SF-36 questionnaire 
• 6-Minute Walk Test/Borg Score 
• Laboratory tests: 
1. Liver function markers (AST/ALT) 
2. Renal function markers (creatinine and potassium) 
• Echocardiography 
• Collect and review weight diary and dispense new weight diary 
Assessments to be performed at BWH: 
• Laboratory tests: to be performed at BWH at time of CPET-Innocor. 
1. Troponin-I 
2. Collagen III 
3. N-terminal procollagen type I 
4. IL-6 
5. NT-BNP 
6. Urine pregnancy test for women of child-bearing potential 
• CPET-Innocor™ 
• Dispense supply of study drug 
Telephone Calls: Day 3, Phase I (after initiation of placebo or spironolactone) and then every 2 weeks from Baseline 
(Days 28, 42, and 70, Phase I). Telephone calls will not occur on days of clinic visits. 
• Telephone call to monitor compliance, AEs, use of concomitant medications and weight 
Days 14 and 56, Phase II assessments are listed below: 
• Physical exam and vital signs (blood pressure, heart rate, and respiratory rate). Weight to be measured. 
• Laboratory tests: 
1. Renal function markers (creatinine and potassium) 


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• Assess medication compliance 
Day 90, Phase II assessments are listed below: 
Day 90 Phase II visit will require a visit to the enrolling center and then a visit to BWH for CPET-Innocor and collection of 
research biomarker blood samples. The visit to BWH needs to be scheduled 24 to 72 hours after the visit at the enrolling 
center. 
Assessments to be performed during visit at local sites: 
• Physical exam and vital signs (blood pressure, heart rate, and respiratory rate). Weight and height to be measured. 
• SF-36 questionnaire 
• 6-Minute Walk Test/Borg Score 
• Laboratory tests: 
1. Liver function markers (AST/ALT) 
2. Renal function markers (creatinine and potassium) 
3. Inflammatory Biomarkers 
• Echocardiography 
• Collect and review weight diary 
Assessments to be performed at BWH: 
• Laboratory tests to be performed at BWH at time of CPET-Innocor. 
1. Troponin-I 
2. Collagen III 
3. N-terminal procollagen type I 
4. IL-6 
5. NT-BNP 
6. Urine pregnancy test for women of child-bearing potential 
• CPET-Innocor™ 
• Assess medication compliance 
• Collect all study drug and study drug containers. Study drug will be collected from subjects at BWH. 


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Drugs and Dosing 
The proposed dose of ambrisentan was selected based on retrospective data demonstrating that spironolactone is most 
effective in combination with ambrisentan at 5 mg/d and 10 mg/d.4 The rationale for the proposed spironolactone dose 
and treatment timing is based on pharmacological studies5 and data from clinical trials indicating that 50 mg/d inhibits 
vascular mineralocorticoid receptor-dependent activity sufficiently in patients with forms of cardiovascular disease relevant 
to PAH.6 We selected a wash out period of 21 days, which is of sufficient duration to extinguish relevant circulating drug 
levels of this therapy as well as effects of spironolactone on pulmonary vascular function and structure,1,2 and is 
comparable to previously published reports studying the effects of spironolactone on insulin resistance in heart failure7 
and endothelial function in obesity.8 
Ambrisentan (a selective endothelin type-A [ETA] receptor antagonist) is an FDA approved treatment for PAH. Participants 
who qualify to be enrolled in the study are receiving ambrisentan as standard of care for treatment of PAH. Participants 
must be on a stable dose of ambrisentan (5mg/d – 10 mg/d for >3 mo.). Ambrisentan is taken once daily, preferably in the 
morning, with or without food. 
Spironolactone is a synthetic, steroidal antimineralocorticoid agent with additional antiandrogen and weak progestogen 
properties, as well as some indirect estrogen and glucocortoid effects, which is used primarily as a diuretic and 
antihypertensive, but also for the purpose of reducing elevated or unwanted androgen activity in the body. It acts 
predominantly as a competitive antagonist of the aldosterone receptor, and belongs to a class of pharmaceutical drugs 
known as potassium-sparing diuretics. Spironolactone is an FDA approved medication. 
The spironolactone tablets provided as 25, 50 or 100 mg strengths. 
Placebo tablets are identical in size, shape, and color to spironolactone. 
Eligible participants will then be randomized to receive placebo or spironolactone (50 mg/d) for 90 days (Phase I). At the 
completion of Phase I, participants will undergo repeat end-point assessment followed by a 21-day drug wash out period. 
Then, the 90 day crossover phase of the trial will occur (Phase II), in which participants randomized to placebo in Phase I 
will be treated with spironolactone (50 mg/d) in Phase II and vice versa. At the conclusion of Phase II, end-point measures 
are reassessed. 


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Once all entry criteria have been met and random treatment assignment confirmed, the first dose of study drug 50 mg 
should be taken by the subject with or without food. Study drug should be taken once daily, preferably in the morning. 
Spironolactone/placebo will be dispensed to patients at Brigham and Women’s Hospital (BWH) at the time they are having 
the CPET-Innocor™ at Baseline, Phase 1 and Day 1, Phase II Visits. All drug containers will be returned to BWH at Day 
90, Phase I and Day 90, Phase II Visits. 
Study drug to be stored at room temperature. 
Side effects of spironolactone include headache, diarrhea, cramps, drowsiness, rash, nausea, vomiting, irregular 
menstrual periods, and irregular hair growth. Fluid and electrolyte imbalance such as hyperkalemia may occur. 
Gynecomastia may also occur and is related to dose and duration of therapy. It usually reverses upon discontinuation of 
spironolactone. 
 
VI. Biostatistical Analysis 
Endpoints 
Study Primary End-points: A two-primary end-point study model10 will be used in this study, to include change from 
baseline (study drug day 1) at study drug day 90 for each of the two trial phases in (i) 6 minute walk distance and (ii) peak 
VO2 at the completion of exercise as a determinate of overall cardiopulmonary fitness. 
Study Secondary End-points: The secondary end-points are change from baseline (study drug day 1) at study drug day 
90 for each of the two trial phases for cardiac output assessed noninvasively by the Innocor™ device11, the minute 
ventilation/volume of expired carbon dioxide (VE/VCO2) slope at the completion of exercise as assessed by the Innocor™ 
step protocol; echocardiographically assessed RV geometry (RV dimensions, RV fractional area chage, RV area and 
volume), pulmonary artery acceleration time, morphology of the pulmonary artery outflow tract Doppler envelope, and 
tricuspid annular plane systolic excursion (TAPSE) to assess RV function; and quality of life assessed by the SF-36 scale. 


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Innocor™ assessments and analysis of echocardiography and Innocor™ results will be performed at a single core facility 
(Brigham and Women’s Hospital). 
Additional Measures: Assessing volume status 
Compared to other traditional diuretic pharmacotherapies, spironolactone induces a weak natriuretic effect to modulate 
subtle changes to circulating blood volume.4 However, in order to assess the potential effect of spironolactone on 
outcome in PAH due to diuresis rather than change in pulmonary vascular function, several clinical measures indicative of 
volume status will be assessed. These include, regular body weight measurement and jugular venous pressure 
monitoring assessed at 4-week intervals according to previously published methods,12 as well as a record of all study 
participants’ relevant cardiovascular medication (and doses) such as loop and thiazide diuretics. Tracking this information 
will allow for the study investigators to analyze outcome results according to diuretic status, and provide information 
regarding timing and extent to which spironolactone influences circulating plasma volume clinically. 
Statistical Methods 
A two-primary end-point study model will be used in the proposed trial, which is akin to previously published clinical trial 
reports in pulmonary arterial hypertension,10 as follows: 
Physiological Measure of Performance: Peak VO2 
Peak oxygen consumption (pVO2) is a continuous response variable, and we will be comparing ΔpVO2 from baseline to 
90 days, and baseline to 180 days between control and intervention group. Difference in ΔpVO2, from baseline (day 1) to 
day 90, the treatment effect, will be compared using a 2-sided, paired Student’s t test. There are few data on the 
distribution of change in VO2 with interventions. Our prior studies, in patients with congenital heart defects, have shown 
that change in pVO2 is normally distributed.11 In our observational study of patients with congenital heart disease, those 
who engaged in frequent activity increased pVO2 by 1.8±3.2 mL/kg/min. This study included very heterogeneous 
diagnoses and levels of baseline pVO2, and we anticipate the variance of the current study to be significantly lower. A 
true 1.0 ml/kg/min ΔpVO2 difference would be clinically important. If the true difference in mean response of matched 
pairs is 1.0±1.7 ml/kg/min, we will need 25 subjects to be able to reject the null hypothesis with probability (power) 0.80 


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with associated Type I error of 0.05. To account for loss to follow-up or incomplete data, we will enroll 30 subjects. 
Calculations performed using PS power and sample size program.12 
Statistical analyses 
The proposed strategy for statistical analyses of end-points is illustrated in Figure 2. All end-points will be analyzed by 
comparing change in outcome from study drug day 1 to study drug day 90. End-points will be summarized descriptively by 
treatment, and treatment effect will be compared using methods appropriate for a 2x2 crossover design. We do not 
anticipate substantial carry over effects by placebo or spironolactone on outcome measures due, in part, to the lengthy 
study drug wash out period. 
Wash Out 
 
Study Drug Day 
1 
90  1 
90 
 
 
 
 
Timing of End-point 
Measurements 
Δ pVO2 
Δ pVO2 
 
 
Figure 3. Stastical ananlysis schema. The CAPS-PAH trial proposes a prospective, randomized, placebo-controlled cross-over 
design to test the effect of spironolactone therapy on outcome in pulmonary arterial hypertension. In Phase I, patients on stable 
therapy with ambrisentan (5 -10 mg/d) will be randomized to treatment with placebo or spironolactone (50 mg/d) and testing relevant 
to the study end-points, such as peak volume of oxygen consumption (pVO2), will occur at study day 1 and day 90. Following a 21- 
day drug wash out period, subjects will enter into Phase II of the trial, which is characterized by cross-over to opposite therapy of 
Phase I. Repeat end-point assessment will be performed at study drug day 1 and study drug day 90 of Phase II. Change in 
performance on end-points from study drug day 1 at study drug day 90 while receiving spironolactone will be compared to change in 
Phase I 
Phase II 


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performance from study drug day 1 at study drug day 90 while receiving placebo, using a 2-sided, paired Student’s t test. Carryover 
and period effects will be tested using appropriate methods prior to testing the treatment effect. 
 
VII. 
Risks and Discomforts 
Risks of Spironolactone: 
Common Side Effects 
• Skin rash 
• Headache 
• Dizziness 
• GI symptoms of nausea, vomiting, gas, diarrhea and stomach pain 
• Cramps 
• Drowsiness 
• Irregular menstrual periods 
• Irregular hair growth 
Less Common Side Effects 
• Hyperkalemia 
• Gynecomastia 
 
Risks of the 6- Minute Walk Test: 
• Fatigue 
• Fainting 
• Muscle soreness 
• Muscle strain or injury. 
Risks of Blood Draws: 
• 
Bruise or pain where the blood samples are taken 
• 
Small risk of infection 


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• 
Lightheadedness and/or fainting 
 
Risks of Cardiopulmonary Exercise Test with Innocor™ 
• Increased dyspnea 
• Fatigue 
• Muscle soreness 
• Chest pain 
• Irregular heart beat 
• Heart attack which has happened rarely 
Participants will be monitored constantly during this test. 
 
VIII. Potential Benefits 
Participants may not benefit from taking part in this study. 
Potential benefit may be to answer the hypothesis of the current proposal is that the addition of spironolactone (50 mg/d) 
to selective ETA inhibition (standard therapy) with ambrisentan (5-10 mg/d) is more effective than standard therapy alone 
at improving cardiopulmonary fitness and quality of life in patients with PAH. 
 
IX. Monitoring and Quality Assurance 
Data Safety Monitoring Plan 
The principal investigator will designate a Medical Monitor (TBD) to be responsible for the safety monitoring of the data for 
this protocol. A Medical Monitor will be appropriate to monitor data and safety because: 
• endpoints are not serious irreversible events; 


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• the intervention is not high risk and the effects of which would not generally be so compelling as to ethically warrant 
early termination for effectiveness; 
• this protocol is offering short term treatment where effects are evaluated over periods of a few months; 
• a smaller number of subjects where the study is completed quickly and the risk can be adequately assessed 
through simple comparisons. 
The study is a three center study (all local hospitals) with a total of thirty subjects being enrolled. Subjects to be enrolled 
will have the diagnosis of PAH and being treated with combination therapy: ambrisentan 5-10 mg every day and sildenafil 
or tadalafil at any pulmonary hypertension therapeutic dose. 
 
The safety data will be reviewed as the research team obtains information from the subjects. This information will be 
obtained at every clinic visit or by telephone. 
Conference calls for all 3 sites will be made every 10-12 weeks. During conference calls a discussion of safety issues will 
be discussed. 
The range of possible study events that could have an important impact on the risks and benefits of research subjects is 
narrow. All events of toxicity that occur will be promptly submitted to the IRB. 
Confidentiality 
In order to maintain subject privacy, all case report forms (CRFs), study drug accountability records, study reports, and 
communications will identify the subject by initials and the assigned subject number. The Investigator will grant auditor(s) 
from regulatory authority(ies) access to the subject’s original medical records for verification of data gathered on the CRFs 
and to audit the data collection process. The subject’s confidentiality will be maintained and will not be made publicly 
available to the extent permitted by the applicable laws and regulations. 


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References 
1. Badesch DB, et al. Diagnosis and assessment of pulmonary arterial hypertension. J Am Coll Cardiol 2009 Jun 30 
2. Galie N, et al. Guidleines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2009 Dec 
3. Simonneau G, et al. Updated clinical classification of pulmonary hypertension J Am Coll Cardiol 2009 Jun 30 
4. Hassoun P, et al. Characterization of connective tissue disease-associated pulmonary arterial hypertension from REVEAL: 
Identifying systemic sclerosis as a unique phenotype. Chest 201 Dec 
5. Sitbon O, et al. Prevalence of HIV-related pulmonary arterial hypertension in the current antiretroviral therapy era. Am J 
Respir Crit Care Med 2008 Jan 1 
6. Maron BA, et al. Aldosterone inactivates the endothelin-B receptor via a cysteinyl thiol redox switch to decrease pulmonary 
endothelial nitric oxide levels and modulate pulmonary arterial hypertension. Circulation 2012;126:963-974. 
7. Preston IR, et al. Mineralocorticoid receptor antagonism attenuates experimental pulmonary hypertension. Am J Physiol Lung 
Cell Mol Physiol 2012;304(10):L678-688. 
8. Maron BA, et al. Effectiveness of spironolactone plus ambrisentan for treatment of pulmonary arterial hypertension (from the 
[ARIES] Study-1 and -2 Trials). Am J Cardiol. 2013, In press. 
9. Lang CC, et al. Ease of noninvasive measurement of cardiac output coupled with peak VO2 determination at rest and during 
exercise in patients with heart failure. Am J Cardiol 2007;99(3):404-405. 
10. Ubeda Tikkanen A, et al. Physical activity is associated with improved aerobic exercise capacity over time in adults with congenital 
heart disease. Int J Cardiol 2013; In press. 
11. Maron BA, et al. Effectiveness of spironolactone plus ambrisentan for treatment of pulmonary arterial hypertension (from the 
[ARIES] Study-1 and -2 Trials). Am J Cardiol. 2013, In press. 
12. Maron BA, Leopold JA. Aldosterone receptor blockers: effective but often forgotten. Circulation 2010 Feb 23;121(7):934-9. 
13. Pitt B, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure: Randomized 
Aldactone Evaluation Study Investigators. NEJM 1999;341:709-717. 
14. Ogino K, et al. Spironolactone, not furosemide, improved insulin resistance in patients with chronic heart failure. Int J Cardiol 2014 
Feb 15;171(3):398-403. 
15. Maron BA, et al. Aldosterone increases oxidant stress to impair guanylyl cyclase activity by cysteinyl thiol oxidation in vascular 
smooth muscle cells. J Biol Chem. 2009 Mar 20;284(12):7665-72. 
16. Leopold JA, et al. Aldosterone impairs vascular reactivity by decreasing glucose-6-phosphate dehydrogenase activity. Nature 
Medicine. 2007 Sep;13(2):189-97. 


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Appendices 
Appendix A 
PROCEDURE FOR 6-MINUTE WALK EXERCISE TEST AND BORG 
DYSPNEA SCALE 
General Procedures 
The six minute walk exercise test should be administered by the same tester (if possible) and on the same course at each 
study site throughout the study for a given subject. The administration of the test and specifications of the testing area 
should be generally consistent with the American Thoracic Society guidelines and the usual practice of the investigative 
site [ATS guidelines; 2002]. 
The area used for the six minute walk test should be pre-measured at approximately 30 m in length (but no shorter than 
15 m [16 yards or 50 feet] in length at minimum) and at least 2 to 3 m in width. There should be no turns or curves to the 
six minute walk area. The length should be marked with gradations to ensure the accurate measurement of the distance 
walked. The area should be well ventilated. The tester may be at the starting end of the corridor or at the midpoint of the 
corridor with a stop-watch. Intermittent rest periods are allowed if the subject can no longer continue. If the subject needs 
to rest briefly, he/she may stand or sit and then begin again when he/she is sufficiently rested but the clock will continue to 
run. At the end of 6 minutes, the tester will call “stop” while simultaneously stopping the watch and then measure the 
distance walked. The Borg dyspnea rating will be administered immediately following completion of the 6MWT. 
Instructions to the Subject 
Subjects will be instructed that the preceding meal should be light. Subjects should be told to wear comfortable clothing 
and sneakers or comfortable walking shoes. The person administering the test will use the following exact dialogue with 
the subject: 
“The purpose of this test is to find out how far you can walk in six minutes. You will start from this point and follow the 
hallway to the marker (e.g. chair) at the end, turn around and walk back. When you arrive back at the starting point you 


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will go back and forth again. You will go back and forth as many times as you can in the 6-minute period. You may stop 
and rest if you need to. Just remain where you are until you can go on again. However, the most important thing about the 
test is that you cover as much ground as you possibly can during the six minutes. I will tell you the time, and I will let you 
know when the 6 minutes are up. 
When I say STOP, please stand right where you are.” 
After these instructions are given to the subject, the person administering the test will then ask: 
“Do you have any questions about the test?” 
“Please explain to me what you are going to do.” 
The person administering the test will then start the test by saying the following to the subject: 
“Are you ready?” 
“Start when I say “GO.” 
The person administering the test will tell the subject the time at 2 and 4 minutes by saying: 
“You have completed 2 minutes.” 
And then by saying: 
“You have completed 4 minutes.” 
No other instruction or encouragement will be given during the test. Eye contact with the subject should be avoided during 
the test. 
Following the walk, the person administering the test will obtain a rating of dyspnea using the Borg Scale. The person will 
use the following dialogue: 


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“I would like to use the following scale to indicate the maximal shortness of breath you had during the walk test (indicate 
the Borg Scale). If there was no shortness of breath at all you would point to 0; if the shortness of breath was not very 
great you would choose from 0.5 to 2; if you were somewhat more short of breath you would select 3; and if the breathing 
was getting very difficult, you would choose 4 to 9, depending on just how hard it was; 10 represents the greatest 
shortness of breath you have ever experienced in your life, and if you feel more short of breath than you have ever been 
in your life before, choose a number greater than 10 that represents how short of breath you feel. If one of 
the numbers does not exactly represent how short of breath you are, then you can choose a fraction between. For 
example, if you had shortness of breath somewhere between 4 and 5, you could choose 4 ½. 


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Appendix B 
WHO FUNCTIONAL CLASSIFICATION FOR PULMONARY 
HYPERTENSION 
Class I: Patients with pulmonary hypertension but without resulting limitation of physical activity. Ordinary physical activity 
does not cause undue dyspnea or fatigue, chest pain, or near syncope. 
Class II: Patients with pulmonary hypertension resulting in slight limitation of physical activity. These subjects are 
comfortable at rest, but ordinary physical activity causes undue dyspnea or fatigue, chest pain or near syncope. 
Class III: Patients with pulmonary hypertension resulting in marked limitation of physical activity. They are comfortable at 
rest. Ordinary activity causes undue dyspnea or fatigue, chest pain, or near syncope. 
Class IV: Patients with pulmonary hypertension with inability to carry out any physical activity without symptoms. These 
subjects manifest signs of right heart failure. Dyspnea and/or fatigue may be present even at rest. Discomfort is increased 
by any physical activity. 


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Appendix C 
 
Renal Function 
Markers 
Liver Function 
Markers 
Biochemical 
Assessments 
Creatinine 
AST 
Troponin-I 
Potassium 
ALT 
Collagen III 
N-terminal procollagen type I 
IL-6 
NT-BNP 
Aldosterone 
Urine pregnancy test will be performed on women of child-bearing age at Phase 1, Day 1 and Phase 2, Day 1 


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Appendix D 
Weight Diary 
Date 
(Month / Day) 
Time 
(circle AM or PM) 
Weight 
(in lbs) 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 


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Date 
(Month / Day) 
Time 
(circle AM or PM) 
Weight 
(in lbs) 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 


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Date 
(Month / Day) 
Time 
(circle AM or PM) 
Weight 
(in lbs) 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
/ 
: 
AM/PM 
NOTES: 


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Appendix E 
GUIDELINES AND DEFINITIONS FOR RECORDING ADVERSE EVENTS 
The Principal Investigator or a designated member of his / her staff will probe each subject for any AEs that may have 
occurred. The Investigator should always ask the same question when conducting the verbal probe in order to ensure 
uniformity between subjects. The Investigator should ask: 
“How are you doing (feeling)?” 
Based on the subject’s response to this question, the Investigator should ask additional 
questions relevant to the specific complaint such as: 
“How severe is/was the symptom?” 
“How often did the symptom occur?” 
“How long did the symptom last?” 
Using provided definitions, the Investigator will then: 
(1) rate the intensity and seriousness of the AE, (2) estimate the causality of the AE to study 
drug, and (3) note actions taken to counteract the AE. 
Definitions of Intensity, Seriousness, Causality, Action Taken, and Outcome 
INTENSITY 
An assessment of the relative intensity (severity) of an AE is based on the Investigator’s clinical judgment. The maximum 
intensity encountered during the evaluation period should be checked. The assessment of intensity should be 
independent of the assessment of the seriousness of the AE. 


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SERIOUSNESS 
A serious AE is one that represents an actual or potential significant hazard. This includes, but is not limited to, an event 
that is fatal, life-threatening, permanently or severely disabling, requires or prolongs inpatient hospitalization, is a 
congenital abnormality (offspring of subject) or is medically significant (important medical events that may not result in 
death, be life-threatening, or require hospitalization may be considered a serious AE when, based upon appropriate 
medical judgment, they may jeopardize the subject and may require medical or surgical intervention to prevent one of the 
outcomes listed in this definition). 
CAUSALITY 
An estimate of causality between a specified AE and the study drug is made by the Investigator. Definitions of the 
categories follow: 
• NOT RELATED- there is not a temporal relationship to study drug administration (too early, or late, or study drug 
not taken), or there is a reasonable causal relationship between another drug, or concurrent disease and the SAE. 
• POSSIBLE – there is a reasonable causal relationship between the study drug and the SAE. Dechallenge 
information is lacking or unclear. 
• PROBABLE- there is a reasonable causal relationship between the study drug and the SAE. The event responds to 
dechallenge. Rechallenge is not required. 
ACTION TAKEN 
TEST AGENT DOSE MODIFICATION* 
• Dose Increased – the dose or regimen of the test agent was increased. 
• Dose Not Changed – the dose or regimen of the test agent was not changed. 
• Dose Reduced – the dose or regimen of the test agent was decreased. 
• Drug Interrupted – administration of the test agent was stopped temporarily 
• Drug Withdrawn - administration of the test agent was stopped permanently and not restarted 
• Unknown – changes to the administration of the test agent cannot be determined 


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 OUTCOME 
• Fatal – The study subject died 
• Not Recovered / Not Resolved – The AE was ongoing 
• Recovered / Resolved – The AE resolved 
• Recovered / Resolved with Sequelae – The AE is considered resolved however there is a residual sequelae. 
• Recovering / Resolving – The AE is improving but is not yet completely recovered /resolved 
• Unknown – The outcome of the AE cannot be determined. 
SERIOUS ADVERSE EVENTS 
Medwatch form needs to be completed and faxed to the FDA and a copy sent to Bradley Maron, MD (Sponsor of study). 
Send the Medwatch forms to the attention of Laurie Lawler, RN fax # 617-264-6873 
Medwatch forms can be completed electronically at: 
https://www.accessdata.fda.gov/scripts/medwatch/index.cfm?action=professional.reporting1 
OR 
Medwatch form which can be printed from: 
http://www.fda.gov/downloads/AboutFDA/ReportsManualsForms/Forms/UCM163919.pdf 


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Appendix F 
Cardiopulmonary Exercise Test with Innocor™ 
Exercise Protocol: Patients complete a trial of incremental exercise to a symptom-limited maximum. The tests are 
performed with the subject breathing room-air. Two minutes of rest are followed by 2 min of unloaded cycling/step 
protocol at 40-60 RPM. Work rate is continuously increased using a ramp protocol at 10, 15, 20 or 25 W/min. Ventilation, 
pulmonary gas exchange, heart rate (HR), and BP are measured continuously. A 12-lead EKG is obtained at rest and 
each minute of exercise. 
Hemodynamic Measurements: Innocor™ gives the complete metabolic and hemodynamic profile comprising a 
conventional cardiopulmonary exercise test (CPET) together with non-invasive measurement of cardiac output. This 
unique combination enables the possibility to distinguish between ventilatory, central circulatory or peripheral causes of 
exercise intolerance. 
By using inert gas rebreathing for the hemodynamic measurements the hazards and costs of using PA-catheters are 
eliminated and inaccuracies of other non-invasive methods avoided. 
During a rebreathing test the subject rebreathes an oxygen enriched mixture containing very small amounts of two 
physiologically inert gases - one blood soluble and one insoluble component - from a closed rebreathing system. The test 
lasts about 5 breaths or 15 seconds. During this time the blood soluble gas is dissolved in the blood perfusing the ven- 
tilated parts of the lungs. Innocor™ measures the concentration curve of the blood soluble gas and calculates the wash- 
out rate, which is proportional to the Cardiac Output. Cardiac output will be measured at “Rest” and then at “Peak” 
exercise. In patients with a significant intra-pulmonary shunt, the shunt flow is calculated by using the well proven Fick 
principle for oxygen. The blood insoluble gas is measured to determine the lung volume and to account for other factors 
that affect the distribution of the blood soluble gas. 
Physiologic Measurements: All exercise tests are performed at the BWH Cardiopulmonary Exercise Laboratory under the 
supervision of David Systrom, M.D., using an upright cycle ergometer/step protocol. Innocor™ will be utilized to obtain 
metabolic and spirometric data. 


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The following parameters will be obtained during the CPET: 
 
Hemodynamic 
Derived Hemodynamic 
Metabolic 
Spirometric 
CO = Cardiac Output 
SvO2 = Mixed venous oxygen 
saturation 
VO2 = Oxygen uptake 
FEV1 = Forced expiratory volume in 1 second 
CI = Cardiac index 
A-V O2 diff = Arterio-venous 
O2 saturation difference 
VO2/kg = Oxygen uptake per kg 
FVC = Forced vital capacity 
SV = Stroke volume 
VO2 = Oxygen uptake (by 
rebreathing) 
VO2/HR = Oxygen pulse 
FEV1% = FEV1/FVC 
SI = Stroke index 
VO2/kg = Oxygen uptake per 
kg (by rebreathing) 
VCO2 = Carbon dioxide excretion 
PEF = Peak expiratory flow 
PBF = Pulmonary 
blood flow 
Shunt = Intrapulmonary shunt 
fraction 
R = Respiratory exchange ratio 
MEF 75, = Max. instantaneous forced expiratory 
flow 
VL = Lung volume (or 
FRC) 
SYS = Systolic blood pressure 
VE = Expiratory minute ventilation 
MEF 50, = (75%, 50% and 25% of FVC 
remaining, 
HR = Heart rate 
DIA = Diastolic blood pressure 
VA = Alveolar ventilation 
MEF 25 = respectively) 
SpO2 = Arterial 
oxygen saturation 
MAP = Mean arterial blood 
pressure 
VD = Anatomical dead space 
FET = Forced expiratory time 
SVR = Systemic vascular 
resistance 
VT = Tidal volume 
MVV = Maximum voluntary ventilation 
SVRI = Systemic vascular 
resistance index 
fB = Respiratory rate 
CPO = Cardiac power output 
FETO2 = End-tidal concentration of oxygen 
CPI = Cardiac power index 
FETCO2 = End-tidal concentration of carbon 
dioxide 
VE/VO2 = Ventilatory equivalent for oxygen 
VE/VCO2 = Ventilatory equivalent for carbon 
dioxide 
VE/VCO2 slope = Slope of VE versus VCO@ 
AT = Anaerobic threshold (V-slope method) 
RC = Respiratory compensation (V-slope) 
BR = Breathing reserve 


Amendment 4 24-Aug-2016 
PROTOCOL CAPS-PAH 
Page | 40 
 
 
 
 
Appendix G 
Inflammatory Biomarkers Substudy 
for 
The Combination Ambrisentan Plus Spironolactone in 
Pulmonary Arterial Hypertension Study (The CAPS-PAH Study) 
PI: 
 
 
Rationale: Mineralocorticoid receptor (MR) is known to alter and promote inflammation and fibrosis in the systemic 
vasculature. For example, MR inhibition, or genetic deletion results in decreased production of interleukin 1β (IL1β), IL-6, 
IL-12, and monocyte chemotactic protein-1 (MCP1). 
Inflammation and fibrosis are also two markers of pulmonary vascular disease, both in experimental models and in human 
disease. For example, PAH patients have increased levels of circulating cytokines such as IL-6, and they predict survival. 
Moreover, treatment with recombinant IL-6 or IL-6 overexpression are associated with experimental PH. Therefore, IL-6 
production may participate in pulmonary vascular remodeling. 
We hypothesize that MR inhibition in PAH patients alters the cytokine profile toward an anti-inflammatory pattern, with 
decrease in IL-6 pathway markers and increase in anti-inflammatory cytokines. 
Procedures: 
10 cc of heparinized blood (purple top) will be collected and plasma will be obtained. 
Time points: Baseline; End of stage 1; End of stage 2. 
Blood to be cenrtifuged to separate plasma. Store plasma in 1.5 or 2 ml storage tubes for -80C freezer. 
Store the samples at local site. Samples to be shipped in batches of 6 samples. Samples will be labeled with unique 
subject number date and time of collection. Samples to be shipped to Ioana Preston, MD at the following address: 
Tufts Medical Center 


Amendment 4 24-Aug-2016 
PROTOCOL CAPS-PAH 
Page | 41 
 
 
 
 
800 Washington street 
 
Boston, MA02111 
Tel 617-636-7609 
Tests to be performed from each sample: 
• IL-6 
• IL-6R 
• Gp130 
• IL10 
• TNF-α 
• IL-1β 
• IL-2 
• IFN-ɤ 
To measure cytokines, we will use ELISA assay (simple assay or multiplex assays, Bio-Rad) 
Analysis: Wilcoxon Mann-Whitney-U test will be used for nonparametic distributions.