Statin Therapy in Heart Failure: Potential Mechanisms of Benefit

Study Overview
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Brief Summary
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The goal of the investigators' study is to further understand the potentially beneficial effects of statin therapy in patients with heart failure. It is hypothesized that statins will 1) increase the heart's pumping ability 2) improve functioning of the sympathetic nervous system and 3) decrease immune activation in heart failure.

Detailed Description
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Recent evidence suggests that HMG-Coenzyme A (statin) therapy may be associated with improved survival in both ischemic and non-ischemic heart failure (HF). Large, randomized outcome studies of statins in HF are currently underway, but these trials will not address underlying mechanisms. The aim of the study is to investigate statins' potentially beneficial mechanisms of action in HF, focusing on: 1) sympathetic nervous system activation and 2) myocardial remodeling, and 3) immune activation in heart failure. Fifty patients with systolic HF of non-ischemic etiology from a single center will be randomized in a double-blinded fashion to 3 months of atorvastatin 10mg QD (25 subjects) vs matching placebo QD (25 subjects). The following exams will be performed at baseline (pre-treatment) and at end of study (post-treatment): sympathetic microneurography, echocardiography, and peripheral blood chemokine analysis. Sympathetic microneurography at the peroneal nerve will directly quantify changes in sympathetic nerve activity (bursts/minute). Echocardiography (with the addition of MRI in a subset of subjects without pacemakers or implantable defibrillators) will be used to track changes in cardiac structure and function; indices of remodeling will include measurement of left ventricular mass index, left ventricular volume indices, left ventricular ejection fraction, and subendocardial scar quantification (MRI only). Immune activation will be characterized by circulating cytokines and chemokines. Additionally, quantification of established cardiac biomarkers (cardiac troponin, B-type natriuretic peptide, and C-reactive Protein), Holter monitor/heart rate variability studies, and quality of life and global clinical assessment will be performed pre- and post- treatment. Neither sympathetic microneurography nor MRI have been previously utilized to assess statins' effects in humans with HF. The impact of statin therapy on inflammatory chemokine activation in HF also has not been studied. The knowledge gained from our proposed investigations may serve as a basis for understanding how statin therapy has potential to improve clinical outcomes in HF, and may ultimately lead to new therapeutic strategies for HF.

Official Title
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A Double-blind Randomized, Placebo-Controlled, Single-Center Study to Assess the Impact of Statins on the Autonomic Nervous System and Cardiac Structure/Function in Non-Ischemic Heart Failure

Conditions
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Heart Failure, Congestive

Intervention / Treatment
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* Drug: atorvastatin
* Drug: placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age≥18 years old LVEF ≤ 35%, as documented by echocardiography, radionuclide ventriculography, gated SPECT, or contrast ventriculography within past 6 months Symptomatic HF (NYHA II-IV) or current NYHA I with history of symptomatic HF within the last year Stable doses of optimal HF medical therapy, unless documented contraindication. Exclusion Criteria: Ischemic etiology of HF, defined as the presence of at least one of the following four criteria; angiographic evidence of > 50% lesion in 1 or more of the 3 major epicardial vessels; history of myocardial infarction; history of revascularization procedure; evidence of significant perfusion defect in the setting of ischemic symptoms. Clinical indication for statin treatment - coronary artery, cerebrovascular, or peripheral vascular disease Major cardiovascular event or surgical procedure within past 8 weeks LDL<70 mg/dL HF secondary to congenital heart disease or uncorrected valvular disease Treatment with statin within past 2 months Pregnancy Contraindication to statin: moderate liver disease, AST/ALT > 150 U/ L, known hypersensitivity Likely to receive heart transplant within 3 months Known peripheral or autonomic neuropathy

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: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: active treatment<br>atorvastatin 10mg QD x 3 months | Drug: atorvastatin<br>* atorvastatin 10mg PO QD<br>* Other names: lipitor;|
| Placebo Comparator: placebo<br>matched placebo QD x 3 months | Drug: placebo<br>* matched placebo Qd x 3 months<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| LVEF (Left Ventricular Ejection Fraction) | Left ventricular ejection fraction was assessed by transthoracic echocardiography according to Simpson's rule (biplane method of disks). | baseline and three months | 
| Muscle Sympathetic Nerve Activity (by Sympathetic Microneurography) |  | Baseline and three months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Left Ventricular End-diastolic Dimension (LVEDD) | The end-diastolic dimension of the left ventricle (in mm) was measured with 2D echocardiography performed by experienced technicians using Acuson Sequoia Echocardiography System | Baseline and three months | 
| Cardiac Biomarker Level BNP | B-type natriuretic peptide, measured pg/mL at baseline and post-treatment | Baseline, 3 months | 
| High-sensitivity C-reactive Protein (hsCRP) as a Cardiac Biomarker |  | Baseline, Three months | 
| Cardiac Troponin I (cTnI) | Participants with cTnI ≥0.04 ng/mL | Baseline, Three months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Randomized Controlled Trial, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Sympathetic Nervous System, Ventricular Remodeling, Chemokines