Treatment of HFpEF With Nitrate Supplement

Study Overview
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Brief Summary
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The objective of this project is to determine if Neo40, a nitric oxide generating lozenge, when consumed twice daily by subjects with HFpEF, will increase exercise tolerance, decrease symptoms and improve quality of life for patients.

Detailed Description
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Heart failure (HF) is the most common principal diagnosis for hospital admission in patients over 65 years old. There are two types of HF, those with reduced ejection fraction (HFrEF) and those with preserved ejection fraction (HFpEF). Approximately half of patients with the clinical syndrome of HF have preserved systolic function. HEpEF is becoming more prevalent with aging of the population and obesity. There are only two class I recommendations for the treatment of HFpEF, which are controlling blood pressure and the use of diuretics to relieve symptoms. Exercise training is another approach to improving symptoms, however it may be poorly tolerated. Nitrate supplement in the form of concentrated beetroot juice was recently shown to improve exercise tolerance in patients with HFpEF. (1) Beetroot juice contains high concentration of nitrate (NO3). This is metabolized to nitrite (NO2). It enters the blood stream, where it is further reduced to nitric oxide (NO) resulting in intense vasodilation. Patients with diastolic dysfunction are often asymptomatic at rest but complain of dyspnea with exertion. Increase in heart rate with exercise causes reduced diastolic filling time and increases left sided filling pressure. Borloug, et al demonstrated this with right heart catheterization and supine exercise in patients with diastolic dysfunction. Infusion of NO2 resulted in decreased filling pressures and increased cardiac output. (2) Neo40 is a new product made from concentrated beetroot juice in the form of a lozenge designed to dissolve on the tongue. NO3 supplement causes vasodilatation only in the setting of hypoxia and acidosis resulting in targeted vasodilatation.

Official Title
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Treatment of HFpEF With Nitrate Supplement: A Double-blind, Placebo Controlled Trial Including Patients With Atrial Fibrillation

Conditions
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Heart Failure With Normal Ejection Fraction

Intervention / Treatment
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* Dietary Supplement: Active lozenge
* Drug: Placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Diagnosis of HFpEF, defined as: symptomatic with one of more of the following: orthopnea, paroxysmal nocturnal dyspnea, lower-extremity edema, dyspnea on exertion; AND ejection fraction >50% ratio of early mitral inflow velocity to septal tissue dopler velocity >8; AND one or more of the following: left atrium measurement >34 mL/m2, elevated N-terminal pro-brain natriuretic peptide level within the past 12 months, long term loop diuretic use for control of symptoms or elevated filling pressures on prior cardiac catheterization Stable medical therapy, defined as: no change in cardiac medications within 30 days Willing to comply with the protocol and provide written informed consent Exclusion Criteria: Non-cardiac condition causing limitation of exercise tolerance Acute coronary syndrome, myocardial infarction or cardiac revascularization within 60 days Clinically significant valvular disease, defined as moderate-severe or severe stenosis or insufficiency Significant ischemia seen on stress testing within the past 12 months that was not revascularized Subject has taken and investigational medication within the past 30 days History of allergy to beets Systolic blood pressure of <100 at screening Significant medical condition that would interfere with treatment, safety or compliance with the protocol

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Crossover Assignment
Interventional Model Description: Double-blind, placebo controlled crossover study
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Active lozenge first<br>Subject will take active lozenge (Vitamin C, Vitamin B12, Nitric Oxide Blend, L-citrulline, Sodium Nitrite) for one week, perform cardiac testing then take placebo lozenge for one week and perform cardiac testing. | Dietary Supplement: Active lozenge<br>* nitric oxide generating lozenge<br>Drug: Placebo<br>* placebo tablet<br>|
| Active Comparator: Placebo lozenge first<br>Subject will take placebo lozenge for one week, perform cardiac testing then take active lozenge (Vitamin C, Vitamin B12, Nitric Oxide Blend, L-citrulline, Sodium Nitrite) for one week and perform cardiac testing. | Dietary Supplement: Active lozenge<br>* nitric oxide generating lozenge<br>Drug: Placebo<br>* placebo tablet<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time on Treadmill | change in total time traveled on treadmill | after one week of active lozenges compared to one week of placebo lozenges | 
| Metabolic Equivalents | change in metabolic equivalents on treadmill | after one week of active lozenges compared to one week of placebo lozenges | 
| E/E Prime | change in E/E prime on exercise echo (E/E prime is a ratio between early mitral inflow velocity and mitral annular early diastolic velocity in order to measure diastolic dysfunction) | after one week of active lozenges compared to one week of placebo lozenges | 
| Estimated Right Ventricular Systolic Pressure | change in estimated right ventricular systolic pressure on echo | after one week of active lozenges compared to one week of placebo lozenges | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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HFpEF, Heart failure, Nitrate supplement