Metabolic Manipulation in Chronic Heart Failure

Study Overview
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Brief Summary
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Conventional measures used for the treatment of chronic heart failure act predominantly by reducing the work performed by the heart. In a recent study, the investigators showed that one drug (perhexiline) substantially improved symptoms and cardiac function in heart failure. The investigators wish to confirm these findings and test whether or not this drug acts by altering the heart's energy source thus augmenting the energetic status and work efficiency of the heart.

Detailed Description
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Perhexiline maleate is an antianginal agent which increases the efficiency of energy production by shifting substrate utilisation from free fatty acids towards glucose. We showed that perhexiline therapy was highly effective in improving exercise capacity, symptoms and cardiac function in patients with systolic heart failure of both ischaemic and non ischaemic aetiology. Perhexiline acts by inhibiting both carnitine palmitoyl transferase-1 (CPT-1) and CPT-2, which are key enzymes in mitochondrial free fatty acid uptake. This leads to increased myocardial glucose substrate utilization. Further we wish to ascertain whether or not this drug improves cardiac energetics and efficiency by altering substrate utilization. In this proposal we will assess the cardiac function (by cardiac Magnetic Resonance Imaging MRI), cardiac energetic status (by cardiac Magnetic Resonance Spectroscopy MRS), cardiac efficiency (via pressure-volume loops) and substrate utilization (via left and right heart catheterization), following one month of perhexiline therapy or placebo in patients with symptomatic idiopathic dilated cardiomyopathy on optimal conventional heart failure medications. An interim analysis is planned after 20 patients.

Official Title
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Metabolic Manipulation in Chronic Heart Failure

Conditions
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Chronic Heart Failure

Intervention / Treatment
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* Drug: Perhexiline
* Drug: Placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Optimally-medicated idiopathic dilated cardiomyopathy Symptomatic ( NYHA IIb-III) Impaired left ventricular systolic function (EF < 40%) Exclusion Criteria: Abnormal liver function tests (defined as above twice the upper limit of normal (ULN)) Concomitant use of Amiodarone , Quinidine , Haloperidol or Selective serotonin (5HT) uptake inhibitors such as Fluoxetine and Paroxetine which may inhibit the CYP2D6 enzyme. Pre-existing evidence of peripheral neuropathy. Women of childbearing potential. Patients with implantable cardiac devices (or any other contraindication to MRI). Obesity ( BMI > 32) Obstructive sleep apnea syndrome Patients with known hypersensitivity to perhexiline Patients with impaired renal function (Creatinine > 250 µmol/L) Valvular heart disease defined as more than moderate valvular stenosis or regurgitation. Atrial Fibrillation

Ages Eligible for Study
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Minimum Age: 16 Years
Maximum Age: 90 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: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Perhexiline<br>perhexiline 100mg bd for 1 month duration | Drug: Perhexiline<br>* 100mg o bd<br>* Other names: Pexsig;|
| Placebo Comparator: Placebo<br>placebo one tablet bd for 1 month duration | Drug: Placebo<br>* 1 tablet bd<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in cardiac energetics as demonstrated by resting myocardial PCr/ATP ratio from cardiac MRS |  | 1 Month | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in mechanical efficiency (external work / MVO2) |  | 1 Month | 
| Change in respiratory quotient |  | 1 Month | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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perhexiline, idiopathic dilated cardiomyopathy, magnetic resonance spectroscopy, cardiac energetics