Prognostic Value of Precision Medicine in Patients With MINOCA (PROMISE Trial).

Study Overview
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Brief Summary
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The aim of our study is to evaluate if the use of a precision-medicine approach with a specific therapy tailored on the underlying pathogenic mechanism will improve the quality-of-life in MINOCA patients. The investigators further aim at investigating wherever a precision-medicine approach will improve the prognosis, healthcare related costs, and if that a different profile of plasma biomarkers and microRNAs may serve as diagnostic tools for detecting specific causes of MINOCA and to assess response to therapy. Finally, beyond its pivotal role in differential diagnosis, the investigators hypothesize that cardiac magnetic resonance (CMR) may provide a morphological and functional cardiac characterization as well as help in the prognostic stratification.

Detailed Description
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PROMISE study is a randomized multicenter prospective superiority phase IV trial comparing precision medicine approach versus standard of care in improving the prognosis and/or the quality-of-life of patients presenting with MINOCA. Patients will be randomized 1:1 to precision medicine approach consisting of a comprehensive diagnostic work up aim at elucidating the pathophysiological mechanism of MINOCA and consequently a tailored pharmacological approach versus standard of care consisting of standard diagnostic algorithm and therapy for myocardial infarction. The aim of the study is to evaluate if the use of a precision-medicine approach with a specific therapy tailored on the underlying pathogenic mechanism will improve the quality-of-life in MINOCA patients (primary objective). The investigators further aim at investigating wherever a precision-medicine approach will improve the prognosis, healthcare related costs, and if that a different profile of plasma biomarkers and microRNAs may serve as diagnostic tools for detecting specific causes of MINOCA and to assess response to therapy (secondary objectives). Finally, beyond its pivotal role in differential diagnosis, the investigators hypothesize that cardiac magnetic resonance (CMR) may provide a morphological and functional cardiac characterization as well as help in the prognostic stratification (secondary objective). The study is a multicentre trial involving 3 centers: IRCCS Fondazione Policlinico Universitario A. Gemelli (Study Promoter), Centro Cardiologico Monzino IRCCS, IRCCS Policlinico San Donato. It will include 180 patients aged >18 years hospitalized for MINOCA randomized 1:1 to a precision medicine approach consisting of a comprehensive diagnostic work-up, analysis of circulating biomarkers and micro RNA expression profile and pharmacological treatment specific for the underlying cause versus a standard approach consisting of routine diagnostic work-up and standard medical treatment.

Official Title
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PROgnostic Value of Precision Medicine in Patients With Myocardial Infarction and Non-obStructive Coronary artEries: the PROMISE Trial.

Conditions
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Myocardial Infarction With Non-Obstructive Coronary Arteries

Intervention / Treatment
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* Procedure: Coronary angiography
* Diagnostic Test: OCT imaging
* Procedure: Percutaneous coronary intervention (PCI):
* Diagnostic Test: Acetylcholine provocative test
* Diagnostic Test: TT-Echocardiography
* Diagnostic Test: TE/contrast echocardiography
* Diagnostic Test: Cardiac magnetic resonance
* Diagnostic Test: Circulating biomarkers
* Drug: Antiplatelet Drug
* Drug: Statin
* Drug: Beta blocker
* Drug: ACEi/ARB
* Drug: CCB
* Drug: Nitrates
* Drug: Anticoagulant


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Ability to give informed consent to the study Age > 18y MINOCA diagnosis, defined as: Acute myocardial infarction (based on Fourth Universal Definition of Myocardial Infarction Criteria): Evidence of non-obstructive coronary artery disease on angiography (i.e., no coronary artery stenosis >50%) in any major epicardial vessel. No specific alternate diagnosis for the clinical presentation (i.e. non-ischemic causes of myocardial injury such as sepsis, pulmonary embolism, and myocarditis). Exclusion Criteria: Inability or limited capacity to give informed consent to the study Age < 18 y Pregnant and breast-feeding women or patients considering becoming pregnant during the study period will be excluded. For women of childbearing potential, the use of a highly effective contraceptive measure is required in order to be included in the study. Highly effective contraceptive is defined in accordance with the recommendations of the Clinical Trial Facilitation Group as a contraceptive measure with a failure rate of less than 1% per year (https://www.hma.eu/fileadmin/dateien/Human_Medicines/01-About_HMA/Working_Groups/CTFG/2020_09_HMA_CTFG_Contraception_guidance_Version_1.1_updated.pdf). Alternate diagnosis for the clinical presentation (i.e. non-ischemic causes of myocardial injury such as sepsis, pulmonary embolism, valve disease, hypertrophic cardiomyopathy and myocarditis). Also patients presenting with Takotsubo syndrome will be excluded. Contraindication to contrast-enhanced CMR, eg, severe renal dysfunction (glomerular filtration rate <30 mL/min), non-CMR-compatible pacemaker or defibrillator. Contraindication to drugs administrated: e.g a history of hypersensitivity to drugs administrated or its excipients, significant renal and/or hepatic disease. Patients with comorbidities having an expected survival <1-year will be excluded.

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
Interventional Model Description: Patients will be randomized 1:1 (using an online software available 24h/24h) to precision medicine approach vs standard approach.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Precision medicine approach<br>Comprehensive diagnostic work-up with: Coronary angiography and ventriculography in all patients OCT at the time of coronary angiography in the cath-lab. Acetylcholine provocative test (to assess the presence of coronary vasospasm) at the time of coronary angiography in the cath-lab. TE-Echo and/or CE-Echo (if distal/microvascular embolization is suspected) Blood sampling for circulating biomarkers and miRNA expression profile Trans-thoracic echocardiography in all patients during the index hospitalization CMR in all cases during the index hospitalization. Targeted pharmacological treatment specific for the underlying cause: DAPT ± stent implantation (if required), statins, beta-blockers, ACEi/ARB (in case of evidence of plaque rupture/erosion) CCB and/or nitrates (in case of documentation of coronary vasospasm) Anticoagulation (in case of coronary embolism). | Procedure: Coronary angiography<br>* coronary angiography will be performed via the transradial or transfemoral approach with the use of a 6F sheath. Coronary angiography will be performed within 90 minutes from hospital admission in patients presenting with persistent ST-segment elevation, and within 48 hours in patients presenting with non-ST-segment elevation. Unfractionated heparin (initial weight-adjusted intravenous bolus of 60 IU/Kg, with repeat boluses to achieve an activated clotting time of 250 to 300 seconds) was administered in all patients. If evidence of plaque rupture<br>Diagnostic Test: OCT imaging<br>* OCT imaging will be performed in the culprit artery in all patients randomized to the precision medicine approach. A 0.014-inch guidewire will be placed distally in the target vessel and an intracoronary injection of 200 µg of nitroglycerine will be performed. Frequency domain OCT (FD-OCT) images are acquired by a commercially available system (C7 System, LightLab Imaging Inc/ St Jude Medical, Westford, MA) connected to an OCT catheter (C7 Dragonfly; LightLab Imaging Inc/ St Jude Medical, Westford, MA), which was advanced to the culprit lesion. The FD-OCT run will be performed using the integrated automated pullback device at 20 mm/s. During image acquisition, coronary blood flow will be replaced by continuous flushing of contrast media directly from the guiding catheter at a rate of 4 ml/s with a power injector in order to create a virtually blood-free environment.<br>Procedure: Percutaneous coronary intervention (PCI):<br>* PCI with stent implantation will be considered in selected cases with evidences of plaque rupture<br>Diagnostic Test: Acetylcholine provocative test<br>* ACh will be administered in a stepwise manner into the left coronary artery (LCA) (20-200 μg) or into the right coronary artery (RCA) (20-50 μg) over a period of 3 min with a 2-3 min interval between injections. Coronary angiography will be performed 1 min after each injection of these agents and/or when chest pain and/or ischaemic ECG shifts were observed. The decision of testing with provocative test LCA or RCA as first will be left to the discretion of the physicians; both LCA and RCA will be tested if the first test was negative. Angiographic responses during the provocative test will be assessed in multiple orthogonal views in order to detect the most severe narrowing and/or analysed by using computerized quantitative coronary angiography (QCA-CMS, Version 6.0, Medis-Software, Leiden, The Netherlands).<br>Diagnostic Test: TT-Echocardiography<br>* TT-Echo will be used to calculate left and right ventricular and atrial dimensions, left and right ventricular systolic function, transmitral flow Doppler spectra, mitral and tricuspidal valve annulus tissue Doppler spectra, ejection time and stroke volume, inferior vena cava, aorta and pulmonary artery diameters and Doppler spectra, according to the recommendations of the American Society of Echocardiography.<br>Diagnostic Test: TE/contrast echocardiography<br>* In patients with angiographic evidence or suspicion of distal microembolization, TE-Echo consisting of an echocardiographic probe inserted in to the oesophagus will be used to detect a hidden cardioembolic source (i.e. left atrial thrombus); in patients with suspected left ventricular source of cardioembolism, contrast echocardiography consisting of a 0.3ml solution of SONOVUE will be used.<br>Diagnostic Test: Cardiac magnetic resonance<br>* CMR will be performed during hospital stay on a 1.5-T system equipped with a 32-channel cardiac coil. Patients underwent conventional CMR including cine, T2-weighted, first pass perfusion, and conventional breath-held late gadolinium enhancement (LGE).<br>Diagnostic Test: Circulating biomarkers<br>* Blood sampling for circulating biomarkers and miRNA expression profile at the time or within 12 hours of coronary angiography. Blood sampling will be processed and analysed in the research laboratory of the Department of Cardiovascular Science. Biological aliquots will be preserved at XBiogem Biobank at Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome (see section 33).<br>Drug: Antiplatelet Drug<br>* acetylsalicylic acid (loading dose 250mg intravenously followed by 75mg orally) + P2Y12 receptor inhibitor (i.e. Clopidogrel, 300 or 600mg loading dose orally, followed by 75 mg orally daily).<br>Drug: Statin<br>* i.e. atorvastatin; dosages titrated on the patient's clinical characteristics<br>Drug: Beta blocker<br>* i.e. bisoprolol; dosages titrated on blood pressure, ECG, heart rate<br>Drug: ACEi/ARB<br>* i.e. ramipril; dosages titrated on blood pressure, ECG, heart rate<br>Drug: CCB<br>* i.e. diltiazem; dosages titrated on blood pressure, ECG, heart rate<br>Drug: Nitrates<br>* i.e. nitroglycerine; dosages titrated on blood pressure, ECG, heart rate<br>Drug: Anticoagulant<br>* i.e. warfarin; the selection of the anticoagulant agent will be based on the clinical scenario, contraindications etc<br>|
| Other: Standard approach<br>Routine diagnostic work-up with: Coronary angiography and ventriculography Transthoracic echocardiography in all patients during the index hospitalization CMR with contrast media only if clinically indicated (i.e. to exclude myocarditis or takotsubo syndrome) Standard medical treatment with: DAPT in all patients Beta-blockers (if indicated by the clinical context, i.e. documentation of left ventricular ejection fraction <50%, tachycardia). High intensity statins in all patients ACEi/ARB (if clinically indicated). | Procedure: Coronary angiography<br>* coronary angiography will be performed via the transradial or transfemoral approach with the use of a 6F sheath. Coronary angiography will be performed within 90 minutes from hospital admission in patients presenting with persistent ST-segment elevation, and within 48 hours in patients presenting with non-ST-segment elevation. Unfractionated heparin (initial weight-adjusted intravenous bolus of 60 IU/Kg, with repeat boluses to achieve an activated clotting time of 250 to 300 seconds) was administered in all patients. If evidence of plaque rupture<br>Diagnostic Test: TT-Echocardiography<br>* TT-Echo will be used to calculate left and right ventricular and atrial dimensions, left and right ventricular systolic function, transmitral flow Doppler spectra, mitral and tricuspidal valve annulus tissue Doppler spectra, ejection time and stroke volume, inferior vena cava, aorta and pulmonary artery diameters and Doppler spectra, according to the recommendations of the American Society of Echocardiography.<br>Diagnostic Test: Cardiac magnetic resonance<br>* CMR will be performed during hospital stay on a 1.5-T system equipped with a 32-channel cardiac coil. Patients underwent conventional CMR including cine, T2-weighted, first pass perfusion, and conventional breath-held late gadolinium enhancement (LGE).<br>Drug: Antiplatelet Drug<br>* acetylsalicylic acid (loading dose 250mg intravenously followed by 75mg orally) + P2Y12 receptor inhibitor (i.e. Clopidogrel, 300 or 600mg loading dose orally, followed by 75 mg orally daily).<br>Drug: Statin<br>* i.e. atorvastatin; dosages titrated on the patient's clinical characteristics<br>Drug: Beta blocker<br>* i.e. bisoprolol; dosages titrated on blood pressure, ECG, heart rate<br>Drug: ACEi/ARB<br>* i.e. ramipril; dosages titrated on blood pressure, ECG, heart rate<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Angina status | Angina status will be evaluated using the single-item angina stability scale and the two-item angina frequence scale of the Seattle Angina Questionnaire (SAQ). Scores are calculated by summing items within a dimension and transforming it to a 0-100 scale, where 0 is the worst and 100 the best possible level of health. * To reduce the risk of detection and performance bias, a team of 2 cardiologists blinded to group allocation and belonging to an external cardiology unit will submit and collate the questionnaires from study participants. | 1-year follow-up | 
| Quality of life | Quality of life will be evaluated using the nine-item scale of physical limitations scale, the three-item treatment satisfaction scale and two-item disease perception scale of the Seattle Angina Questionnaire (SAQ). Scores are calculated by summing items within a dimension and transforming it to a 0-100 scale, where 0 is the worst and 100 the best possible level of health. * To reduce the risk of detection and performance bias, a team of 2 cardiologists blinded to group allocation and belonging to an external cardiology unit will submit and collate the questionnaires from study participants. | 1-year follow-up | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rates of major adverse cardiovascular events | Rates of major adverse cardiovascular events (MACE; composite of all-cause mortality; re-hospitalization for myocardial infarction, stroke or heart failure; repeated coronary angiography) will be evaluated at 1-year follow-up in MINOCA patients. | 1-year follow-up | 
| Healthcare primary related-costs | Healthcare primary related costs will be evaluated as mean costs (including procedures, tests, medicines). | 1-year follow-up | 
| Healthcare secondary related-costs | Healthcare secondary related-costs will be evaluated as mean quality adjusted life year (QALY) gained. | 1-year follow-up | 
| Healthcare secondary related-costs | Healthcare secondary related-costs will be evaluated as the incremental cost-effectiveness ratio (ICER) expressed as the cost per QALY. | 1-year follow-up | 
| Ability of different circulating biomarkers as diagnostic biomarker and stratification tool for specific causes of MINOCA. | Measurement of cardiac circulating biomarkers: -miRNAs (miR-16, miR-26a, miR-145, miR-222, miR-155-5p, miR-483-5p, miR-45): to measure miRNA reverse transcriptase polymerase chain reaction (RT-PCR) will be employed and results will be expressed in relative expression (2-ΔΔCT Method). | during index hospitalization (at the time or within 12 hours of coronary angiography) | 
| Ability of different circulating biomarkers as diagnostic biomarker and stratification tool for specific causes of MINOCA. | Measurement of cardiac circulating biomarkers: -Endothelin 1: It will be assessed through ELISA immunoassay and results will be expressed in Picograms per millilitre (pg/mL). | during index hospitalization (at the time or within 12 hours of coronary angiography) | 
| Ability of different circulating biomarkers as diagnostic biomarker and stratification tool for specific causes of MINOCA. | Measurement of cardiac circulating biomarkers: -Neuropeptide Y: It will be assessed through ELISA immunoassay and results will be expressed in Picograms per millilitre (pg/mL). | during index hospitalization (at the time or within 12 hours of coronary angiography) | 
| Ability of different circulating biomarkers as diagnostic biomarker and stratification tool for specific causes of MINOCA. | Measurement of cardiac circulating biomarkers: -soluble CD40 ligand: It will be assessed through ELISA immunoassay and results will be expressed in Picograms per millilitre (pg/mL). | during index hospitalization (at the time or within 12 hours of coronary angiography) | 
| Ability of CMR in evaluating different mechanisms of MINOCA and their prognostic value through morphological and functional cardiac characterization. | Morphological cardiac characterization will be assessed by measurement of left and right ventricle volumes (in ml or ml/m2). | from day 3 to day 7 from the acute coronary event | 
| Ability of CMR in evaluating different mechanisms of MINOCA and their prognostic value through morphological and functional cardiac characterization. | Morphological cardiac characterization will be assessed by measurement of the presence of myocardial edema using T2-weighted sequences and a 17 segments assessment model of cardiac segmentation. | from day 3 to day 7 from the acute coronary event | 
| Ability of CMR in evaluating different mechanisms of MINOCA and their prognostic value through morphological and functional cardiac characterization. | Morphological cardiac characterization will be assessed by measurement of the presence of defect of perfusion using first pass perfusion sequences and a 17 segments assessment model of cardiac segmentation. | from day 3 to day 7 from the acute coronary event | 
| Ability of CMR in evaluating different mechanisms of MINOCA and their prognostic value through morphological and functional cardiac characterization. | Morphological cardiac characterization will be assessed by measurement of the presence of fibrosis using late gadolinium enhancement sequences and a 17 segments assessment model of cardiac segmentation (estimated as LGE % of the cardiac segment involved). | from day 3 to day 7 from the acute coronary event | 
| Ability of CMR in evaluating different mechanisms of MINOCA and their prognostic value through morphological and functional cardiac characterization. | Morphological cardiac characterization will be assessed by measurement of the presence of myocardial infarct size (estimated as grams or % of left ventricular myocardial mass). | from day 3 to day 7 from the acute coronary event | 
| Ability of CMR in evaluating different mechanisms of MINOCA and their prognostic value through morphological and functional cardiac characterization. | Functional cardiac characterization will be assessed by measurement of right and left ventricles eject fraction (estimated as %). | from day 3 to day 7 from the acute coronary event | 
| Ability of CMR in evaluating different mechanisms of MINOCA and their prognostic value through morphological and functional cardiac characterization. | Functional cardiac characterization will be assesaed by measurement of regional kinetic abnormalities using a 17 segments assessment model of cardiac segmentation. | from day 3 to day 7 from the acute coronary event | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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MINOCA, coronary spasm, OCT