Clinical trial NCT04760821: Prevention of Acute Myocardial Injury by Trimetazidine in Patients Hospitalized for COVID-19
Official title: Prevention of Acute Myocardial Injury by Trimetazidine in Patients Hospitalized for Moderate to Severe Acute Respiratory Syndrome Caused by SARS-CoV-2
Study type: INTERVENTIONAL
Overall status: UNKNOWN
Phase: PHASE2
Conditions: Acute Respiratory Distress Syndrome
Covid19
Myocardial Injury
Keywords: Acute Respiratory Distress Syndrome
Coronavirus
Myocardial Injury
Troponin
Trimetazidine
Lead sponsor: Ministry of Health, Brazil
Sponsor class: OTHER_GOV
Collaborators: name: InCor Heart Institute
First posted: 2021-02-18
Enrollment: 80
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: Patients admitted for moderate to severe acute respiratory distress syndrome caused by the SARS-CoV2 will be randomized to usual care or usual care + trimetazidine.
Primary purpose: TREATMENT

Brief summary: Acute myocardial injury has been a finding of variable frequency among patients diagnosed with COVID-19. It is now recognized that cTnI levels are strongly associated with increased mortality. The mechanisms underlying the myocardial injury remain unknown, and it is not clear whether they reflect local/systemic inflammatory process and/or cellular ischemia.

Both myocardial ischemia and ventricular dysfunction result in dramatic changes in mitochondrial oxidative metabolism. These changes involve an increase in the rate of cytoplasmic anaerobic glycolysis to compensate for the decrease in mitochondrial adenosine triphosphate (ATP) production. The rest of the mitochondrial oxidative metabolism originates mainly from the β-oxidation of free fatty acids, which occurs at the expense of glucose oxidation.

Trimetazidine is a competitive inhibitor of the enzyme 3-ketoacyl coenzyme A (CoA) long-chain thiolase (3-KAT), the last enzyme involved in the oxidation of fatty acids. Stimulation of glucose oxidation by trimetazidine results in a better coupling between glycolysis and glucose oxidation, with a consequent decrease in lactate production and intracellular acidosis, present in situations of myocardial ischemia or heart failure.

Thus, the PREMIER-COVID-19 study was designed to test the hypothesis that the use of trimetazidine associated with usual therapy in patients admitted with a diagnosis of moderate to severe acute respiratory syndrome by SARS-CoV2 infection reduces the extent of acute myocardial injury assessed by the peak release of ultra-sensitive troponin compared to usual therapy.

Detailed description: Acute myocardial injury, defined by increased levels of high-sensitivity cardiac troponin I (cTnI), has been a finding of variable frequency among patients diagnosed with COVID-19. This myocardial impairment can occur in the form of acute myocarditis or an injury secondary to the imbalance between oxygen supply and demand (type 2 myocardial infarction). It is now recognized that cTnI levels are strongly associated with increased mortality. The mechanisms underlying the myocardial injury remain unknown, and it is not clear whether they reflect local/systemic inflammatory process and/or cellular ischemia.

Both myocardial ischemia and ventricular dysfunction result in dramatic changes in mitochondrial oxidative metabolism. These changes involve an increase in cytoplasmic anaerobic glycolysis rate to compensate for the decrease in mitochondrial ATP production. Unfortunately, the increase in glycolysis exceeds the subsequent mitochondrial oxidation capacity of pyruvate (glucose oxidation) derived from glycolysis, resulting in the intracellular accumulation of lactate and protons. The protons produced from this decoupling between glycolysis and glucose oxidation contribute to a rupture in ionic homeostasis and myocardial cells, resulting in lower cardiac efficiency. In both the ischemic heart and the insufficient heart, the rest of the mitochondrial oxidative metabolism originates mainly from the β-oxidation of free fatty acids, which occurs at the expense of glucose oxidation.

Trimetazidine is a competitive inhibitor of the enzyme 3-ketoacyl CoA long-chain thiolase (3-KAT), the last enzyme involved in the oxidation of fatty acids. Stimulation of glucose oxidation by trimetazidine results in a better coupling between glycolysis and glucose oxidation, with a consequent decrease in lactate production and intracellular acidosis present in situations of myocardial ischemia or heart failure.

Thus, the PREMIER-COVID-19 study (open and randomized) was designed to test the hypothesis that the use of trimetazidine associated with usual therapy in patients admitted with a diagnosis of moderate to severe acute respiratory syndrome by SARS-CoV2 infection reduces the extent of acute myocardial injury assessed by the peak release of ultra-sensitive troponin compared to usual therapy. Investigators will also assess, as secondary outcomes, the impact on clinical evolution to more severe forms (admission to the intensive care unit or the need for mechanical ventilatory support, length of stay in hospital and in-hospital mortality).

Eligibility criteria: A. Inclusion Criteria:

1. Clinical diagnosis of moderate to severe acute respiratory syndrome due to SARS-CoV2 defined as:

   1.1. Tachypnea: \> 24 breaths per minute 1.2. Hypoxemia: arterial oxygen saturation \<94% in room air by pulse oximetry 1.3. Presumptive (or confirmed) diagnosis of SARS-Cov2 infection by at least one of the following criteria:
   1. Polymerase chain reaction assay (+) for SARS-CoV2
   2. Serology (+) for SARS-CoV2
   3. SARS-CoV2 antigen diagnostic tests (+)
   4. Chest CT with findings suggestive of the diagnosis of COVID-19 in the presence of medical history or clinical signs compatible with the diagnosis of COVID-19
2. Signature of the Informed Consent Form

B. Exclusion Criteria:

1. Chronic renal dysfunction stage 4 (GFR \<30mL / min / 1.73m2 calculated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation
2. Patient on renal replacement therapy by dialysis
3. Pregnant and lactating women
4. Previous use of trimetazidine less than two weeks before hospital admission
5. Any clinical condition at the investigator´s discretion likely to be associated with elevation of baseline hs-troponin \>99th percentile

Primary outcomes:
measure: High-sensitivity cardiac troponin
timeFrame: From enrollment until at least ten days (moderate cases) or twenty days (severe cases) after the beginning of symptoms AND 24 hours without fever AND with improvement in symptoms.
Secondary outcomes:
measure: All-cause mortality assessed at 30 days following randomization
timeFrame: From the first 30 days after randomization
measure: Admission in ICU assessed at 30 days following randomization
timeFrame: From the first 30 days after randomization
measure: Mechanical respiratory support assessed at 30 days following randomization
timeFrame: From the first 30 days after randomization
measure: ICU-free days assessed at 30 days following randomization
timeFrame: From the first 30 days after randomization
measure: Hospital-free days assessed at 30 days following randomization
timeFrame: From the first 30 days after randomization
Other outcomes:
Locations:
city: Sao Paulo
country: Brazil
facility: Heart Institute (InCor-HCFMUSP)
state: SP
Study officials:
affiliation: InCor (HC-FMUSP)
name: Luis Henrique Wolff Gowdak, MD, PhD
role: STUDY_CHAIR
affiliation: InCor (HC-FMUSP)
name: Felipe Gallego Lima, MD
role: PRINCIPAL_INVESTIGATOR
References: