Conditions: Alzheimer's Disease Hypertension
Keywords: Alzheimer's Disease Hypertension
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 14
Healthy volunteers: yes

Brief summary:
Angiotensin converting enzyme inhibitors (ACE-I) are a group of blood pressure-lowering medicines. Some studies suggest that ACE-I, such as ramipril, may help prevent Alzheimer's disease (AD). The purpose of the research is to see how ramipril affects a substance in the body called beta-amyloid. Beta-amyloid is found in the brain and in the liquid around the brain and spinal cord. High amounts of beta-amyloid may be associated with a greater risk of getting Alzheimer's disease. This study will see if ramipril can lower the amount of beta-amyloid in the spinal fluid. This study will also see if ramipril affects blood vessel function and memory and thinking. The investigators hope that future studies will show whether ramipril might prevent memory loss and decrease the chance of developing Alzheimer's disease.

Detailed description:
High blood pressure (BP) in midlife is predictive of Alzheimer's disease (AD) in later life. Similarly, reductions in BP are associated with protection against AD. Treatment with antihypertensive medications, specifically angiotensin converting enzyme inhibitors (ACE-I) such as ramipril, is associated with up to a 55% reduction in the prevalence of AD, suggesting a potentially promising role for ACE-I in the prevention of AD. It is unknown however 1) whether ACE-Is will have the same effect on Cerebrospinal fluid (CSF) Aβ levels in humans as in animal models 2) whether ACE-Is induce changes associated with vascular function (i.e. levels of CSF angiotensin converting enzyme (ACE) and peripheral endothelial function) and 3) whether there are interactions between ACE-I-induced changes in CSF Aβ, CSF ACE and indices of vascular function.

One mechanism by which antihypertensives may protect against AD is via Aβ neuropathology. In order to better understand the mechanisms through which ACE-I may modify CSF Aβ and possibly AD risk, we propose a randomized, double-blind, placebo-controlled pilot clinical trial, enrolling 20 middle-aged (age range 40 - 65 years), mildly hypertensive (between 130 - 160 mmHg mean systolic and between 85 - 100 mmHg mean diastolic) participants, who are adult children of an individual with AD. The main objective of this trial is to examine the effects of the ACE-I, ramipril, on 1) CSF Aβ levels 2) CSF ACE levels and 3) peripheral endothelial function as measured by brachial artery flow-mediated vasodilation (FMD) and aortic augmentation index (AAIx), in middle-aged adults with mildly elevated BP, who are at increased risk of developing AD.

Arms:
arm 1: Matching Placebo arm 2: Ramipril 5mg/day

Interventions: intervention 1: Ramipril intervention 2: Placebo
Intervention descriptions: intervention 1: Ramipril 5 mg/day intervention 2: Matching Placebo

Protocol document:
Prot_SAP_000.pdf: 
 
SEAIRA 2014-1353 Protocol 
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Studying the Effects of Antihypertensives in Individuals  
at Risk for Alzheimer’s Disease (SEAIRA) Pilot Study 
 
NCT00980785 
 
December 5, 2014 
 
 
 
 
 
 


 
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Protocol: “Studying the Effects of Antihypertensives in Individuals at 
Risk for Alzheimer’s Disease (SEAIRA) Pilot Study” 
 
 
 
 
Principal Investigator: 
Cynthia Carlsson, MD, University of Wisconsin 
 
 
Co - Investigators: 
Whitney Wharton, Ph.D., Emory University (Original Principal Investigator at University of 
Wisconsin) 
James H. Stein, MD, University of Wisconsin 
Maritza Dowling, PhD, University of Wisconsin 
Carey Gleason, PhD, University of Wisconsin 
 
 
Collaborator 
Claudia Korcarz, PhD, University of Wisconsin 
 
 
Funding Sponsor 
Alzheimer’s Disease Initiative of the State of Wisconsin 
 
 
 
 
 
 
Contact information: 
Contact information Emory University: 
Whitney Wharton, PhD 
Assistant Professor 
Emory University 
Department of Neurology 
WWHC 1841 Clifton Rd., NE 
Atlanta, GA 30329 
w.wharton@emory.edu 
 
Contact Information University of Wisconsin: 
Cindy Carlsson, MD, MS 
Department of Medicine 
2500 Overlook Terrace 
Madison, WI 53507 
cmc@medicine.wisc.edu 
608.280.7000 
 


 
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Introduction 
Please note, this study completed enrollment as of 3/1/2011.  Per the 5 year renewal policy, this 
study remains open for tissue and data analysis only.  Data and specimens continue to be 
stored at the UW-Madison.  When specimens are analyzed, they will be analyzed at UW-
Madison and the de-identified data resulting from the specimen analysis may be sent to Emory 
University for further analysis. 
 
Project Summary 
High blood pressure (BP) in midlife is predictive of Alzheimer’s disease (AD) in later life. 
Similarly, reductions in BP are associated with protection against AD. Treatment with 
antihypertensive medications, specifically angiotensin converting enzyme inhibitors (ACE-I) 
such as ramipril, is associated with up to a 55% reduction in the prevalence of AD, suggesting a 
potentially promising role for ACE-I in the prevention of AD. It is unknown however 1) whether 
ACE-Is will have the same effect on CSF Aβ levels in humans as in animal models 2) whether 
ACE-Is induce changes associated with vascular function (i.e. levels of CSF angiotensin 
converting enzyme (ACE) and peripheral endothelial function) and 3) whether there are 
interactions between ACE-I-induced changes in CSF Aβ, CSF ACE and indices of vascular 
function.  
One mechanism by which antihypertensives may protect against AD is via Aβ neuropathology. 
In order to better understand the mechanisms through which ACE-I may modify CSF Aβ and 
possibly AD risk, we propose a randomized, double-blind, placebo-controlled pilot clinical trial, 
enrolling 20 middle-aged (age range 40 – 70 years), mildly hypertensive (between 130 – 160 
mmHg mean systolic and between 70 – 100 mmHg mean diastolic) participants, who are adult 
children of an individual with AD. The main objective of this trial is to examine the effects of the 
ACE-I, ramipril, on 1) CSF Aβ levels 2) CSF ACE levels and 3) peripheral endothelial function 
as measured by brachial artery flow-mediated vasodilation (FMD) and aortic augmentation 
index (AAIx), in middle-aged adults with mildly elevated BP, who are at increased risk of 
developing AD. 
 
Hypothesis: mildly hypertensive, middle-aged, non-demented, adult children of persons with 
AD will exhibit lower CSF Aβ and ACE levels and improved endothelial function following 4 
months of ramipril therapy. These vascular effects have been tied to cognition. Later work will 
examine whether ramipril may reduce the risk of AD in later life.  
 
Specific Aim 1: To determine the effects of 4 months of ramipril therapy on CSF Aβ levels in 
mildly hypertensive, non-demented adult children of persons with AD when compared to 
subjects taking placebo. 
 
Specific Aim 2: To evaluate the effects of 4 months of ramipril therapy vs. placebo on CSF 
ACE levels in mildly hypertensive, non-demented adult children of persons with AD when 
compared to subjects taking placebo. 
 
Specific Aim 3: To determine the effects of 4 months of ramipril therapy on the cardiovascular 
outcome variables of brachial reactivity and aortic augmentation index in non-demented adult 
children of persons with AD when compared to subjects taking placebo. 
 


 
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RESEARCH PLAN 
 
A. Hypotheses and Specific Aims 
 
A.1. Rationale: 
High blood pressure (BP) in midlife is predictive of Alzheimer’s disease (AD) in later life. 
Similarly, reductions in BP are associated with protection against AD [1, 2] such that even small 
reductions (<5mmHg systolic and <3 mmHg diastolic) are associated with improvements in Mini 
Mental State Examination (MMSE) [1] scores. Specifically, converging evidence indicates that 
lowering BP alters the pathobiological factors that contribute to AD (see Birns et al. review [2]). 
Treatment with antihypertensive medications, specifically angiotensin converting enzyme 
inhibitors (ACE-I) such as ramipril, is associated with up to a 55% reduction in the prevalence of 
AD, suggesting a potentially promising role for ACE-I in the prevention of AD [3]. ACE-I improve 
endothelial function outside of the central nervous system and decrease Aβ (i.e. a substance 
thought to contribute to neuronal damage in AD) in animal models, suggesting that these are 
mechanisms by which ACE-Is may protect against AD [4]. It is unknown however 1) whether 
ACE-Is will have the same effect on cerebrospinal fluid (CSF) Aβ levels in humans as in animal 
models 2) whether ACE-Is induce changes associated with vascular function (i.e. levels of CSF 
angiotensin converting enzyme (ACE) and peripheral endothelial function) and 3) whether there 
are interactions between ACE-I-induced changes in CSF Aβ, CSF ACE and indices of vascular 
function. 
 
In order to better understand the mechanisms through which ACE-I may modify CSF Aβ and 
possibly AD risk, we propose a randomized, double-blind, placebo-controlled pilot clinical trial, 
enrolling 20 middle-aged (age range 40 –70 years), mildly hypertensive (130 – 160 mmHg 
mean systolic and 70 – 100 mmHg mean diastolic) participants, who are adult children of an 
individual with AD. The main objective of this trial is to examine the effects of the ACE-I, 
ramipril, on 1) CSF Aβ levels 2) CSF ACE levels and 3) peripheral endothelial function as 
measured by brachial artery flow-mediated vasodilation (FMD) and aortic augmentation index 
(AAIx), in middle-aged adults with mildly elevated BP, who are at increased risk of developing 
AD based on familial history. 
 
Our overarching hypothesis is that mildly hypertensive, middle-aged, non-demented, adult 
children of persons with AD will exhibit lower CSF Aβ and ACE levels and improved endothelial 
function following 4 months of ramipril therapy. These vascular effects have been tied to 
cognition. Later work will examine whether ramipril may reduce the risk of AD in later life. 
 
The proposed trial has the potential to draw attention to an extremely promising avenue in AD 
prevention. Specifically, a therapeutic intervention that reduces Aβ levels may delay the onset of 
AD pathology, or possibly one day serve as a treatment strategy. Pilot data collected from the 
current investigation will be used to support a NIH Pathway to Independence grant application 
(K99/R00), which will investigate the effects of centrally acting ACE inhibitors on biomarkers for 
AD (CSF and MRI perfusion), in middle-aged persons at risk for AD. Of note, the K99/R00 
proposal will not only have the power and the length of follow-up needed to address the 
variables included in the current proposal, but it will also be designed to examine cognitive task 
performance. Importantly, the NIA has stated that funding pharmacologic research in order to 
understand the pathobiology of AD is of the highest priority. The current project serves to 
provide preliminary data, as well as to address initial questions surrounding the relationship 


 
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between AD and vascular factors before a larger, more expensive and more targeted research 
project is warranted.  
A.2. Hypothesis:  
We hypothesize that mildly hypertensive, middle-aged, non-demented, adult children of persons 
with AD will exhibit lower CSF Aβ and ACE levels and improved endothelial function following 4 
months of ramipril therapy. These vascular effects have been tied to cognition. Later work will 
examine whether ramipril may reduce the risk of AD in later life. 
A.3. Specific Aims: 
The present study is guided by the following specific aims: 
Specific Aim 1: To determine the effects of 4 months of ramipril therapy on CSF Aβ levels in 
mildly hypertensive, non-demented adult children of persons with AD when compared to 
subjects taking placebo. 
 
Specific Aim 2: To evaluate the effects of 4 months of ramipril therapy vs. placebo on CSF 
ACE levels in mildly hypertensive, non-demented adult children of persons with AD when 
compared to subjects taking placebo. 
 
Specific Aim 3: To determine the effects of 4 months of ramipril therapy on the cardiovascular 
outcome variables of brachial reactivity and aortic augmentation index in non-demented adult 
children of persons with AD when compared to subjects taking placebo. 
 
B. Background and Significance: 
 
B. 1. Vascular Risk Factors and Alzheimer’s disease Neuropathology: Alzheimer’s disease 
(AD) is the most common dementing illness and is associated with significant morbidity and 
mortality among older adults. As many as 5.2 million people in the United States are currently 
living with AD, and this number is expected to exceed 14 million by the year 2050 [5]. In 
Wisconsin alone, 100,000 individuals age 65 and older were diagnosed with AD in 2000. By the 
year 2010, the Alzheimer’s Association predicts that Wisconsin will see a 10 % increase in AD, 
bringing the number of affected persons to a startling 110,000 individuals over the age of 65. 
Although breakthroughs in AD treatments have been made, these therapies work mainly to 
delay further loss of function rather than restore cognitive abilities. Irreversible neuronal loss 
may limit efficacy of therapies once clinical signs of AD have developed, thus, emphasizing the 
importance of developing primary preventive strategies for use in high-risk individuals during the 
preclinical phase. 
A major indication of preclinical AD pathology is Aβ accumulation [6]. The accumulation of Aβ 
plaques has received much attention and could prove to be a modifiable target for AD 
prevention. In AD patients, Aβ plaques are particularly prominent in the CA1 region of the 
hippocampus, a brain region important for memory processes and one that is selectively 
impaired in the presence of elevated BP levels [7]. Specifically, scientists propose that Aβ 
plaques precede cognitive decline in AD patients. Thus, a therapeutic intervention that reduces 
Aβ levels may delay the onset of AD pathology, or possibly one day serve as a treatment 
strategy. CSF Aβ levels are reliable biomarkers of underlying AD neuropathology and have 
been proposed as a biomarker to monitor treatment efficacy [8].  
B. 2.  Vascular Risk Factors and Alzheimer’s disease Neuropathology: An increased risk of 
AD has been associated with numerous vascular risk factors, including hypercholesterolemia, 


 
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[9] hyperhomocysteinemia, [10] diabetes mellitus, [11-13] obesity, [11, 14, 15] physical 
inactivity, [16] elevated inflammatory markers [17] and particularly hypertension [9]. Advancing 
age increases exposure time to age-dependent vascular risk factors, suggesting that the effects 
of “age” on cognitive decline may be mediated in part via vascular risk factors [18]. 
Cerebrovascular dysregulation and Aβ deposition are findings in preclinical AD pathology, are 
integrally related to vascular risk factors, [19-21] and are processes that work synergistically to 
accelerate neuronal degeneration [19]. In the Atherosclerosis Risk in Communities cohort of 
middle-aged persons (mean age 55), the effects of hypercholesterolemia, diabetes, and ApoE 
ε4 on declines in memory over a 6-year interval were additive [22], with greater declines 
occurring in persons with increased risk factors. This suggests that vascular risk factors and 
ApoE ε4 may act synergistically in causing cognitive decline. If aging contributes to AD risk, in 
part, through the accumulation of vascular risk factors, then modifying these risk factors in 
midlife may reduce the detrimental cognitive effects in later life. Thus, it is critical that future 
research investigates the interaction and relative influence of vascular risk factors, genotype, 
gender, and age on the development and progression of AD. 
Hypertension has been closely linked with vascular dementia and cognitive decline [23]. 
Additionally, elevated BP in mid-life has been linked to the development of AD decades later, 
leading to speculation that BP regulation plays a key role in the progression of AD. Recent 
epidemiological [24] observational [7, 25], clinical [3, 23, 26] and basic science [24, 27] suggests 
that some antihypertensive medications may reduce the risk for AD, and even improve cognition 
in patients with AD [28].  
B. 3. ACE-I Improve Cognition in Humans with AD by Decreasing Aβ Levels: One 
mechanism by which antihypertensives may protect against AD is via Aβ neuropathology [4, 
24]. Some of the most promising clinical [3, 26] observational [29] and basic science [24, 27] 
data examining the effects of antihypertensives on AD comes from studies using ACE-I. 
Angiotensin converting enzyme (ACE), a component of the renin–angiotensin system (RAS), 
has been shown to facilitate in the accumulation of Aβ plaques [30, 31], while ACE-I are 
reported to reduce Aβ deposition [32]. The chief rationale for using ACE-I is based on findings 
that ACE receptors are over-expressed in the hippocampus and throughout blood brain barrier 
(BBB) cells in patients with AD [30 {Savaskan, 2005 #5900, 33]. Furthermore, many ACE-Is 
such as the one in the current proposal, have the ability to cross the BBB, a factor that may 
contribute to ACE-I selective ability to treat AD via prevention of Aβ deposition. In fact, studies 
have demonstrated that treatment with centrally acting ACE-I decreases Aβ in animal models of 
AD [32], decreases AD incidence [34] and improves cognitive performance in AD patients [35]. 
These preclinical studies suggest that centrally acting ACE-Is may have AD-modifying activity in 
participants with AD or in those at high risk of developing AD. 
Targeting modifiable risk factors, such as elevated BP, that contribute to Aβ accumulation and 
subsequent AD pathology may be important in developing effective preventive strategies for AD. 
The mechanisms through which adjustable risk factors contribute to neuronal damage may 
potentially be modified. ACE is associated with elevated BP and the accumulation of Aβ plaques 
[16, 19-22]. If the presence of Aβ leads to neuronal damage in part through deregulation of ACE 
levels and elevated blood pressure, then modifying Aβ accumulation through the use of ACE-Is 
may potentially reduce the risk of developing AD in high-risk individuals. 
B. 4. Significance: The proposed 4-month randomized, double-blind, placebo-controlled, pilot 
clinical trial will provide information concerning possible mechanisms underlying the potential 
efficacy of ACE-I to reduce the risk for AD. If ramipril improves CSF Aβ levels and these 
changes correlate significantly with changes in CSF ACE levels, peripheral measures of 
endothelial function and/or cognition in persons at risk for AD, it would strengthen the evidence 


 
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for the role of ACE-I in AD prevention. Preventing or delaying the onset of AD would have a 
profound population health and economic impact on the people of Wisconsin and worldwide. 
B. 5. Importance of Prevention: Recent estimates of the projected rapid increase in the 
prevalence of AD emphasize the importance of early detection, intervention, and prevention of 
the disease.[36] There is increasing evidence that the clinical syndrome of AD is preceded by a 
prolonged and currently irreversible preclinical phase characterized by neuropathological, [37] 
functional, [38, 39] structural, [40] metabolic, [39, 41] and cognitive changes[42-45] typical of 
AD. There is growing evidence that a person’s risk of developing AD may be influenced by 
lifestyle, [46-52] diet, [53-55] vascular risk factors, [9, 10, 12, 14, 17, 56, 57] use of vitamin 
supplements, [58-60] and use of nonsteroidal anti-inflammatory agents [61-63]. However, there 
are currently no known effective interventions targeting these potentially modifiable factors to 
either prevent the development of MCI, postpone the conversion of MCI to AD, [64, 65] or slow 
the progression of established disease [66]. The increasing prevalence of AD, lack of effective 
treatments, and increasing identification of potentially modifiable risk factors emphasize the 
critical need for systematic research targeting preclinical diagnosis and identification of early 
intervention and prevention strategies. 
 
B. 6. Modifiable and Non-modifiable Risk Factors for AD. 
Identification of modifiable risk factors for AD is critical to developing effective prevention 
strategies for the disease. Although some risk factors for AD cannot be changed, the 
mechanisms through which these risk factors contribute to the pathobiology of AD could be 
altered. Studies of preclinical AD have focused on persons with ApoE ε4, which has been linked 
to metabolic, structural and cognitive changes that are suggestive of AD in asymptomatic 
persons. Clinically this translates into an earlier age of AD onset [67] and increased conversion 
of Mild Cognitive Impairment (MCI) to AD in ApoE ε4 carriers [68-70]. ApoE ε4 is also 
associated with increased incidence of cardiovascular disease,[71] central nervous system 
(CNS) lipid dysregulation, [72, 73] and impaired resting CBF in cognitively healthy young adults 
[56]. The association of ApoE ε4 with vascular disease and the rapidly converging data 
supporting the association of vascular risk factors [9, 71, 74-76] with AD pathology supports the 
hypothesis that some of the detrimental effects of ApoE ε4 may be favorably altered by targeting 
modifiable vascular risk factors.  
 
B. 7. Justification for Using Participants at 
Risk for AD: One approach to investigating the 
relative influences of modifiable vascular factors, 
such as hypertension, on the development of AD 
is to study neurobiological factors occurring in 
middle-aged 
individuals 
who 
do 
not 
have 
dementia, but may be at increased risk for 
developing the disease. One such group is the 
adult children of persons with AD who, unlike 
older siblings of persons with the disease, provide 
an opportunity to prospectively study the interplay 
between vascular factors that occur in the 
evolution of preclinical disease and the eventual 
development of symptomatic AD. Surprisingly, 
little is known about this cohort, and most data 
about family history as a risk factor for AD has 


 
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been developed from mixed samples of first-degree relatives. In the REVEAL study, the 
calculated AD risk associated with a family history and ApoE ε4 was additive and is illustrated 
for Caucasian women in Figure 1 [77]. As shown, the risk that a 55-year-old Caucasian woman 
will develop AD by age 80 is less than 10% for the general population, 31% for a female with a 
family history of AD but without ApoE ε4, and 50% if she has a positive family history and one 
ApoE ε4 allele. Another study[78] found that persons with a family history of dementia and ApoE 
ε4 had a 9-fold higher age-specific rate of developing dementia over a 4-year period compared 
with those without a family history and no ApoE ε4. In twin and family studies, presence of one 
or more ApoE ε4 in probands accounts for some, but not all, of the increased risk associated 
with a positive family history of AD.[79-82] Thus, the study of family members provides unique 
opportunities to characterize the precursors of AD, including modifiable vascular risk factors, 
and as of yet unidentified genetic markers. 
 
C. Preliminary Studies  
Prior research conducted by the PI and Co-Is of the proposed study has led to the development 
of the current project [83-85]. Dr. Wharton (PI) has successfully conducted research in 
cardiovascular risk factors, and BP in particular. She independently designed and conducted an 
observational study (N = 105) which reported a positive relation between blood pressure and 
cognition, confirming an inverted U-shaped relationship between BP and aging. Results were 
presented at scientific meetings and published in a high profile journal [84]. Also, Dr. Wharton 
currently has 2 manuscripts under review that focus on cardiovascular risk factors in the elderly. 
In addition, Dr. Wharton is involved in many aspects of the Kronos Early Estrogen Prevention 
Study (KEEPS), a randomized, double-blind, placebo controlled clinical trial examining the 
effects of estrogen therapy on cognition and cardiovascular endpoints. This pilot study will 
provide Dr. Wharton with the opportunity to combine her experience as a research investigator 
in cardiovascular function and her experience with randomized controlled trial (RCT), by 
conducting her first RCT as the principal investigator in conjunction with experienced clinical 
investigators from the WCMP and cardiology. Dr. Carlsson (Co-I) has conducted research 
closely related to the current proposal, including studies involving CSF collection in middle-aged 
adults at risk for AD, which is population of interest in the present application. Data from a 
recently completed study at UW showed that CSF Aβ is a factor directly related to the 
pathologic changes in AD brains and that lower levels have been shown to predict AD 
progression in older adults with memory loss [86]. These findings support the rationale for the 
current proposal and stress the need to address the critical questions posed in this project.  
2014 Update: Results of this trial were published at the annual Alzheimer’s Association 
International Conference  and in the Journal of Alzheimer’s Disease in 2012. Results were also 
used as preliminary data in a NIH K01 Career Development application which was awarded to 
the PI of this trial in 2014, which builds on these findings. As of December 2014 there are 4 
pending grant applications that build on this research.  Since the completion of this study, the PI 
and others have conducted similar research showing the protective effects of RAS acting 
antihypertensives on multiple outcomes including hippocampal volume, cerebral blood flow, 
brain inflammatory markers, cognitive function and perhaps most importantly, reduced disease 
progression from MCI to AD over a 4 year period.  
 


 
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C. 1.  Vascular Risk Factors Are 
Associated with CSF Biomarkers 
of AD Progression in At-Risk 
Adults: In participants at risk for 
developing AD, higher BMI and 
total cholesterol levels in men were 
associated with lower CSF Aβ42 
levels, suggesting possible gender 
differences 
in 
the 
effects 
of 
vascular 
risk 
factors 
on 
the 
pathobiology of AD (Figure 2) [85]. 
In preliminary baseline data from 
the ongoing ESPRIT trial (PI: 
Carlsson), at risk, ApoE ε4 carriers 
with 
increased 
systolic 
blood 
pressureand BMI had CSF Aβ40 and Aβ42 levels and Aβ40/42 ratios suggestive of preclinical 
disease progression. This relationship was not noted in ApoE ε4 non-carriers (data not shown). 
Thus, gender and ApoE ε4 may interact with vascular risk factors to influence risk for AD. 
C. 2. Successful Recruitment Efforts in Studies Including Lumbar Punctures 
Fifty-seven subjects enrolled in the UW IRB approved PAST Pilot and PAST studies, with 50 of 
those participants undergoing CSF collection. Fifty-one individuals have completed the studies 
(46 with CSF data). Subjects tolerated the lumbar punctures well without any unexpected 
adverse effects. Nine of 97 (9.3%) lumbar punctures have resulted in post-lumbar puncture (LP) 
headaches. We have had no other complications to date. All of these participants willingly chose 
to continue participating in the study and undergo a follow-up LP, which did not result in 
headache. Based on our experience, we are confident that the inclusion of lumbar punctures in 
the proposed study will have no significant effect on recruitment for the proposed trial.   
 C. 3. Preliminary Safety Data in Studies Including Lumbar Punctures in Healthy Adults 
Both the PAST Pilot and PAST studies were approved by the UW Human Subjects Committee. 
All subjects provided informed consent and had intact capacity for medical decision-making (see 
Appendix for example consent form). As noted above, 9.3% of LPs have resulted in post-LP 
headaches. We have had no other complications to date. In our studies, we used atraumatic 
Sprotte 20-gauge spinal needles initially then changed to an even smaller needle, Sprotte 22-
gauge. These specific atraumatic spinal needles have been shown in clinical trials to reduce the 
incidence of post-LP headache. For the proposed trial we will be using either a 22-gauge 
Sprotte or a 24-gauge Sprotte, depending on the body habitus of the participant. Incidence rates 
range from 4-6.3% for headaches after procedures using this needle type, depending on the 
gauge of the needle. Similarly to the current study, the protocols for the 2 studies mentioned 
above included 4 months of treatment with a medication (cholesterol lowering) vs. placebo in 
participants at risk for developing AD.  
 
D. Research Design and Methods 
This section contains 1) a summary of the experimental protocol and recruitment and 2) a 
summary of the experimental procedures.  
 
D.1. Summary of Experimental Protocol and Recruitment 
 
Figure 2. PAST Study. Baseline CSF Aβ42 vs. BMI (A) & total cholesterol (B) by 
gender. Figures display raw values (points) and predicted values for women and 
men (lines) using Robust-Estimation Wilcoxon-Score General Linear Modeling. 
B


 
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D. 1. 1. Participants: Twenty middle-aged, asymptomatic adult children of persons with AD will 
be randomized for this 4 month RCT. Inclusion/exclusion criteria are listed in Table 1. The 
majority of participants will be recruited 
from 
the 
Wisconsin 
Comprehensive 
Memory Program (WCMP) registry. Also, 
adult children of persons with AD seen in 
UW Assessment Clinics will be asked by 
the clinician about participation in this 
study. 
These 
methods 
have 
been 
successfully utilized by all co-investigators 
in previous clinical trials [85]. Participants 
may also be recruited via newsletters and 
information 
provided 
at 
educational 
seminars.  
 
Given the extensive resources of the 
WCMP, including trained study personnel 
and a full-time subject recruiter, we 
anticipate that the study can start very 
promptly. We should be able to enroll 2-3 
subjects per month. In an unrelated study, 
Dr. Carlsson (Co-I) was able to recruit 1-2 
subjects per week. Enrolling subjects at 
our proposed rate of 2 to 3 per month will 
allow us to finish recruitment in 1 year and 
complete data collection by the middle of 
year 2. This will leave 6 months for final 
data 
analyses, 
preparation, 
and 
publication of manuscripts. 
 
 
D. 1. 2. Inclusion/Exclusion Criteria     
These are summarized in Table 1.  Designated creatinine levels are based on the 
assumption that almost all participants will be Caucasian and will be between the ages 
of 40 and 70. 
 
D. 1. 3. Study Procedures 
Individuals will attend a total of 5 visits over the course of the 5 month study (Figure 3). Twenty 
(20) individuals will be randomized to treatment for 4 months. At the initial screening visit, 
participants will complete a short questionnaire about their medical history, medication history, 
have safety labs assessed and will have their blood pressure measured. Also, individuals will be 
given information on a self-paced, standardized wellness program including exercise material 
and a nutrition guide, called the Dietary Approaches to Stop Hypertension (DASH) [87] to be 
completed over the next 4 weeks +/- 5 days to adjust for the participant’s schedule. The DASH 
is recommended in national hypertension guidelines [87] and information regarding exercise 
and fitness is based on guidelines from the National Institute on Aging. The purpose of the 
wellness program is to educate participants on ways to improve their health, specifically BP, in 
ways that do not involve medication. After the 4 week (+/- 5 days) wellness program, BP will be 
taken to assess the success of the wellness program. Participants should be seated 5 minutes 


 
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with their legs uncrossed before BP measures are taken. A total of 3 readings will be taken. The 
average of these 3 readings will designate the mean, which will be used to assess study 
inclusion. 
Participants whose BP average remains in the targeted range (mean systolic 130 – 160 mmHg, 
and mean diastolic 70 - 100 mmHg) will be randomized to one of the two treatment arms 
(ramipril vs. placebo). Individuals whose BP is lowered as a result of the wellness program will 
not be included in 
the 
study 
(i.e. 
randomized). For 
subjects who are 
randomized, this 
visit will serve as 
their 
Baseline 
visit. 
The 
20 
subjects will be 
randomized in a 
1:1 ratio by the 
UW 
Pharmaceutical 
Research Center 
(PRC) to receive 
an initial ramipril 
dose of 5mg to 
be 
taken 
once 
daily (N=10) vs. matching placebo (N=10).   
At baseline and the 4 month follow-up visit, participants will have fasting CSF collected, 
complete tests of vascular reactivity (See Vascular Endpoints below), provide an update on 
medical problems and medications, review any potential side effects and complete a 1 hour 
cognitive battery. A fasting blood draw will occur at the baseline visit to assess lipid profile, a 
potential factor in CSF a-beta levels. While cognitive task performance is not a primary outcome 
variable, we include this measure because cognition has been linked to BP and 
antihypertensive medication.  
There will be 2 safety visits between the Baseline and Month 4 visits. The safety visits will be at 
1) week 1-2 and 2) week 3-4 after the Baseline visit. During the 2 safety visits, participants will 
have safety labs (creatinine, potassium and urine pregnancy), have blood pressure taken, report 
any changes in medications or health as well as review and report potential side effects.   
The primary endpoint of the proposed study is to determine the effect of ramipril therapy on CSF 
Aβ levels in a group at risk for developing AD. The secondary endpoints are the effect of 
centrally acting ramipril therapy on CSF ACE levels, biomarkers of peripheral vascular reactivity 
as measured by brachial artery flow-mediated vasodilation (FMD) and aortic augmentation 
index (AAIx) and cognitive task performance. Randomization will be stratified based on sex and 
APOE genotype, a risk factor for AD. Subjects and investigators will be blinded to the identity of 
the medication and BP readings obtained throughout the study. Dr. Carlsson will call in ApoE 
results to the PRC for randomization in order to maintain blinding. Compliance will be assessed 
by pill count at each of the follow-up visits. The study coordinator will review the possible side 
effects related to ramipril at each visit, including mild cough, hyperkalemia and changes in 
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All outcomes outlined in the initial protocol, including ApoE testing, have been completed. 
However, the PI and her collaborators will continue to store all samples and tissue at the UW 
Madison for future testing.  
 
D. 2. Summary of the Experimental Procedures 
D. 2. 1. CSF Collection 
The current study will use state-of-the-art collection techniques that are consistent with the “NIA 
Biospecimens Best Practice Guidelines for the Alzheimer’s Disease Centers” [88]. Dr. Carlsson 
will perform lumbar punctures on all subjects that do not have contraindications to lumbar 
punctures (LPs). A neurologist and anesthesiologist will serve as back up for lumbar puncture 
procedures and LPs will be performed in the fasting state [89]. Subjects will be placed in the 
sitting position and the skin over L4-L5 will be prepped and draped in a sterile manner. A 25-
gauge needle will be used to inject 1% lidocaine as a local anesthetic. A Sprotte 22-gauge 
spinal needle with introducer will be inserted into the L4-L5 interspace using sterile technique. 
Between 15-20 ml of CSF will be collected, and divided into four aliquots using four sterile, 
polypropylene tubes [90] from the UW Laboratory for both collection and storage. CSF samples 
will be transported to the CTRC processing area immediately after collection and distributed into 
0.5 ml aliquots and the fourth CSF sample will be frozen for batched analysis in the Wisconsin 
Comprehensive Memory Program lab of Drs. Craig Atwood. Cynthia Carlsson, MD, MS, 
oversees the CSF Bank and has extensive experience in performing LPs. Over the past 5 
years, Dr. Carlsson has performed over 250 LPs for research purposes for her own studies as 
well as the ADNI and ADCS DHA studies. For those participants consenting to storage of future 
samples, the third tube of CSF will be divided into 0.5 ml aliquots and stored in a -80º C freezer 
in the Madison VA GRECC for up to 10 years for future testing. Freezers are equipped with 
backup power and a telephone alarm system. 
D. 2. 2. Vascular Endpoints 
The primary vascular outcomes are FMD and AAIx. Dr. Stein (Co-Investigator and Director of 
the UW Atherosclerotic Imaging Research Program) will oversee collection and analyses of 
vascular endpoints. Endpoints consist of AAIx and brachial artery FMD. FMD is calculated as 
the ratio of brachial artery diameter after reactive hyperemia to baseline diameter, expressed as 
percentage change. Intraobserver reliability for measurement of the BA diameter is 0.987, 
reflecting an interclass correlation coefficient across all readings and conditions [91]. 
D. 2. 3. Laboratory Evaluation 
 Blood, urine and CSF samples will be collected after a 12-hour overnight fast at baseline and 
month 4 visits. Lipid profile from a fasting blood draw will be done at the baseline visit only. 
Potassium and creatinine levels will be measured from non-fasting blood draws done at 
screening and safety visits using enzymatic precipitation techniques on a Hitachi 747 analyzer 
with standard reagents. These studies will be performed in the UW Hospital Laboratory. 
Samples will be stored indefinably and may be used for ongoing Alzheimer’s Disease related 
research.  IRB approval will be obtained for any future use of data or samples not explicitly 
described in this protocol.  
D. 2. 4. Cognitive Testing   
Following blood and CSF collection, all subjects will be served a light breakfast. At the Baseline 
and Month 4 visits, cognitive tests will be administered by a trained technician according to 
protocols established for each test. The cognitive battery is expected to take 1½ -2 hours to 


 
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complete. To reduce practice effects, alternate forms of the above tests have been identified 
and validated to assure comparability. To control for variations in instrumentation, technicians 
will be trained to use standardized instructions for each test administered and the same 
technician will test a particular subject at each visit. In addition, change-scores will be 
determined for cognitive data obtained at baseline and month 4 visits. The change-scores of the 
ramipril group will be compared to the change scores of the placebo group. In this way, we will 
control for practice effects, and maximize internal validity (95). Details of each cognitive test are 
included in this application. 
D. 3. Descriptions of Rationales for Each Specific Aim 
D. 3. 1. Specific Aim 1: Effects of Ramipril on CSF Aβ40 and Aβ42 
D. 3. 1. 1. Rationale for Evaluation of CSF Aβ42 Levels: Human genetic data have 
associated ACE with AD, and purified ACE has been reported to cleave synthetic Aβ in vitro. 
Also, some studies have found a salutary relationship between CSF Aβ42 levels and 
antihypertensive medications, though the exact mechanism is unclear. One study published 
recently found that low serum potassium levels caused my BP medications, were associated 
with low levels of Aβ42 in cerebrospinal fluid 24 years later in women aged 46 to 60 years of 
age. The study was published in the March 13 issue of Archives of Neurology. With AD 
progression, CSF Aβ levels drop as amyloid is deposited into the brain, emphasizing the 
importance of targeting individuals at risk for AD before clinical symptoms develop. The 
proposed randomized, placebo-controlled, pilot clinical trial will evaluate the effects of 4 months 
of ramipril therapy on CSF Aβ42 levels in cognitively healthy, middle-aged adult children of 
persons with AD. 
 
D. 3. 1. 2. Using Cerebrospinal Fluid to Predict the Risk of AD:  CSF biomarkers such as 
tau, Aβ40, and Aβ42 are emerging as promising research tools to identify those at high risk of 
developing AD [8, 92, 93]. CSF Aβ40 and Aβ42 levels have been shown to be reliable 
predictors of AD and risk of AD [8, 93]. CSF Aβ42 levels detect cognitive decline earlier than 
Aβ40 levels or tau protein, and, therefore, may be the most important CSF biomarker currently 
available in AD prevention research [94]. Aβ40, however, has more potent cerebrovascular 
effects and is the  predominant form of Aβ in the cerebral blood vessels [19].  Thus, monitoring 
Aβ40 levels may provide important information on the mechanism through which CBF is altered 
in those at risk for AD.  Some studies have shown that both CSF Aβ42 and tau levels, when 
used together, provide the greatest sensitivity in predicting persons at risk for cognitive decline 
[86].  Thus, although the primary outcome of the trial will be to monitor the effects of ramipril on 
CSF Aβ42 levels, Aβ40 and tau levels also will be evaluated. 
Unfortunately, the plasma levels of Aβ40 and Aβ42 are unreliable due to low Aβ plasma 
concentrations, binding of Aβ to carrier proteins, and cross-reactivity between Aβ with several 
plasma proteins [95-101]. Some investigators have shown that plasma levels of Aβ42 are 
similar between AD patients and controls [101]. Others have noted an increase in plasma Aβ42 
concentrations in 10 to 20% of sporadic AD patients [102, 103]. Because of the inaccuracy of 
plasma measures at this time, the proposed protocol will measure CSF Aβ levels. Since these 
CSF biomarkers have been shown to be stable when stored at -70°C for up to 15 years, extra 
tubes of CSF will be collected in those participants who agree to future testing of samples [8]. 
 


 
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D. 3. 2. Specific Aim 2: Rationale for Evaluation of Ramipril on CSF Markers of 
Angiotensin Converting Enzyme (ACE)   
Overall, there is evidence that certain components of the renin-angiotensin system (RAS), the 
system that regulates ACE levels, may have a crucial role in learning and memory processes. 
Research has shown that there is a relationship between CSF ACE levels and AD. For instance, 
ACE gene variants are linked to AD risk in several populations. Specifically, studies have 
reported elevated levels of angiotensin-converting enzyme (ACE) in the hippocampus, 
parahippocampal gyrus, frontal cortex, and caudate nucleus of AD patients. The increased ACE 
activity may be directly responsible for cognitive impairment in AD because the enhanced 
formation of angiotensin II would result in an increased inhibitory effect of angiotensin II on 
acetylcholine release. Furthermore, Levels of CSF ACE reduced in Alzheimer’s disease, 
Parkinson’s disease, and supranuclear palsy [104]. 
  
D. 3. 3. Specific Aim 3: Rationale for Evaluation of Ramipril on Vascular Function 
 
One objective of this trial is to examine the effects of the ACE-I, ramipril peripheral endothelial 
function as measured by brachial artery flow-mediated vasodilation (FMD) and aortic 
augmentation index (AAIx). The effect of ACE inhibitors on large and small artery endothelial 
function has been assessed in clinical trials in patients with essential hypertension. It is well 
established that ACE-I reduce blood pressure and improve FMD. For instance, one study 
reported that FMD corrected for resting diameter (FMDcorr) was lower in patients taking ACE-I 
(3.0±0.2%) compared with participants treated with beta-blockers (4.2±0.3%, p<0.01) [105]. 
 
D. 3. 4. Rationale for Cognitive Testing   A three-year study of 3,217 elderly residents of 
Cache County, Utah, initially found that the use of some antihypertensive medications at 
baseline was associated with lower incidence of AD. More recently, ACE-I have been shown to 
influence cognitive task performance in clinical trials specifically targeting AD related memory 
problems. Of note, the current proposed study will incorporate the same cognitive outcome 
measure (the MMSE) that has been shown to be sensitive to ACE-I treatment. Two clinical 
trials, Syst-Eur and PROGRESS both reported improved cognitive test scores in participants 
with mild to moderate AD (controlled for vascular dementia) as a result of treatment with ACE-I.  
 
Furthermore, Sink et al. examined the influence of ACE-I that do and no cross the blood brain 
barrier (BBB). The authors concluded that BBB crossing ACE-I participants in the BBB crossing 
group had a significantly lower incidence of developing AD as well as significantly reduced 
MMSE decline in AD patients compared to CCb and ACE inhibitors. This factor is of particular 
relevance because the ACE-I in the current proposal, ramipril, is an ACE-I that crosses the 
BBB. These results were presented at the AGS 2007 Annual Scientific Meeting: Abstract P36. 
Presented May 5, 2007. 
 
D. 4. Data Analysis and Statistical Considerations The study objective is to evaluate the 
effects of 4 months of ramipril therapy vs. placebo on mean changes in CSF Aβ, ACE and mean 
changes in measures of peripheral endothelial function. While we are not aware of any research 
examining the effect of ACE-Is on CSF Aβ, cognitive improvements due to ramipril have been 
reported in as few as 5 days [29]. In reference to reductions in plasma ACE, ramipril is one of 
the most potent ACE-Is available and has a trough-to-peak ratio around 50% [106, 107]. When 
ACE-Is are injected intracerebroventricularly, Aβ reduction can occur in as few as 2 hours. A 
sample size of 10 subjects per arm should have greater than 80% power to detect an 8% 
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change in endothelial variables. Based on the sample size estimates, 20 subjects will be 
recruited for the 4-month clinical trial.  
Clinical outcome parameters will be described by means and standard deviations at each 
measurement time point. Regression models will be used to evaluate predictors of change in 
CSF variables and endothelial outcomes. Changes in clinical outcome parameters (baseline, 
month 4) will be analyzed using repeated-measures analysis of variance (ANOVA) to assess 
the effects of ramipril vs. placebo, using covariates as applicable (ANCOVA). All tests will be 
two-tailed tests using a significance level of 0.05.  
All data for the SEAIRA trial has now been collected at the UW Madison.  Data collected as a 
part of this study will be shared with Dr. Whitney Wharton, the prior PI of the SEAIRA study, 
now Assistant Professor at Emory University. While at Emory University, Dr. Wharton plans to 
continue analyses on data collected during her time at the University of Wisconsin. We propose 
that this study now become a two-site study with Dr. Wharton’s mentor and Co-I, Dr. Cindy 
Carlsson as the site PI for the University of Wisconsin. All physical data, data specimens 
including stored CSF and blood will remain at the UW. The study should however remain open 
so Dr. Wharton may continue data analyses for this study.  Dr. Wharton will conduct the 
analyses at Emory with coded data. The UW ADRC research team will be the only institution 
with access to this code.  
 
While SEAIRA is now complete, additional analyses on data from this trial need to be 
conducted. To accomplish this goal, data must be transferred to Emory University from the UW. 
Data will be sent electronically via email from the ADRC research team at UW Madison to Dr. 
Whitney Wharton at Emory University. The transfer will be overseen by new UW PI of the 
project – Dr. Cynthia Carlsson. All transmitted data will be coded. The code used to label data 
will be separate from the previously used SEAIRA trial ID number, so that Dr. Wharton will not 
know or have access to the key linking identities with the data. Data to be transferred consists of 
neuropsychological testing data, ApoE4 genotype, abeta and ACE levels and activity in CSF, 
family history status, race, gender, age, self-reported income category, handedness, education 
level, drug randomization assignment, symptom reports during the trial, lab data including HDL, 
LDL, cholesterol levels, potassium, creatine, CSF cell count, smoking history, exercise history, 
medication and medical history information and data confirming study medication compliance.   
 
Data will be transferred immediately upon IRB approval. A member of the UW ADRC research 
team will transfer the coded data via email to Dr. Whitney Wharton at Emory. A data transfer will 
occur once IRB approval has been granted at both the UW and Emory University. This transfer 
will include an Excel and SPSS spreadsheet that was created by Dr. Wharton and contains all 
participant data collected thus far and is detailed above. All data to be transferred to Emory 
University will be coded and UW Madison will retain the key linking subject identities with the 
code numbers. Dr. Wharton will not have access to this key. 
 
At Emory University, Dr. Wharton will store the data on her personal work computer. This 
computer is password protected, and the data saved on it is saved to a secure server. Dr. 
Wharton’s computer is locked in her office when she is not there. 
 
The University of Wisconsin will serve as the lead site/coordinating center for the study as all 
physical data, data specimens including stored CSF and blood will remain at the University of 
Wisconsin; however further data analysis will be conducted at both the UW and Emory 
University.  Dr. Wharton will be responsible for receiving and analyzing data and developing and 
updating the study protocol as needed.  The University of Wisconsin will communicate with and 


 
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disseminate information to Dr. Wharton at Emory as needed to discuss anything related to the 
physical data, W-ADRC or IRB requirements; however Emory will be responsible for 
communicating to the University of Wisconsin regarding data analysis progress, protocol 
updates or other changes to the study.  Any unanticipated events or new information about the 
study will be disseminated to the University of Wisconsin and Emory University immediately. 
 
The UW HS IRB will remain the IRB of record; however Emory University will provide approval 
of their involvement with the study (data analysis by Dr. Wharton only).    
  
E. Human Subjects Research The University of Wisconsin has a humans subjects research 
Multiple Projects Assurance on file with the Office for Protection from Research Risks (M-1285). 
Furthermore, all key personnel have completed an educational program entitled “Human 
Subjects Protection Tutorial at the University of Wisconsin-Madison,” adapted from the NIH 
Computer Based Training on Protection of Human Subjects. (A copy of the UW Human 
Subjects Training Certification Letter is included in the application.)  In addition, all key 
personnel have completed appropriate training for the Health Information Portability and 
Accountability Act (HIPAA). Dr. Wharton, now at Emory University, has completed both Human 
Subjects and HIPAA training required by Emory University.   Emory IRB reviewed the current 
project and determined that no IRB Review will be required at Emory.   
 
E. 1. Involvement of Human Subjects. Twenty middle-aged, asymptomatic adult children of 
persons with AD will be randomized for this 4 month RCT. Subjects will be between the ages of 
40 to 70 years. Special classes of subjects such as children, pregnant women, prisoners, and 
institutionalized individuals will not be enrolled. Children are specifically excluded because the 
goal of the study is to evaluate the effects of antihyperteisives in adult children of patients with 
AD. In order for young children to participate, one of their parents must have AD, meaning the 
parent would most likely be fairly young and have early-onset AD, which is clinically different 
from late-onset AD. Young children are not included in our study. Pregnant women are 
excluded because of regulations barring them from this type of research (i.e. the effects of 
ramipril are designated as pregnancy category ‘D’ by the Food and Drug Administration (FDA). 
This means that there have been studies in pregnant women that show the drug was associated 
with some risk for the fetus. Specifically, the use of ACE inhibitors during the second and third 
trimesters of pregnancy has been associated with fetal and neonatal injury including 
hypotension, neonatal skull hypoplasia, anuria, reversible or irreversible renal failure, and death. 
Current Wisconsin Registry for Alzheimer’s Prevention (WRAP) participants are also excluded 
because the neuropyschological test battery may interfere with the primary endpoints of the 
WRAP study. Other exclusion criteria for study participants are listed in Section D.1. and Table 
1. Subjects will complete health-related questionnaires, have fasting blood tests, lumbar 
punctures, and cognitive testing according to the study protocol summarized in Figure 3. All 
data for this trial has been collected and no further data collection will take place. In addition to 
data being coded with unique identifiers not known to Dr. Wharton, data is also now coded so 
as to not show identifiers such as DOB and visit date. These dates are now coded to reflect 
birth and visit month and year, but not the specific date of either. 
 
E. 2. Sources of Research Material. CSF will be collected from subjects in this study for 
testing related to CSF Aβ and ACE levels. Blood samples will also be collected to monitor 
medication side effects and laboratory safety values. These specimens will be obtained 
specifically for research purposes and to ensure the safety of participants. 
 


 
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 E. 3. Recruitment and consent procedures. Detailed recruitment procedures are described in 
Section  D.1. If registrants are interested in participating, a research staff will meet with them to 
review the inclusion and exclusion criteria, risk, benefits, and consent form with them. Subjects 
will be given opportunity to review the risks and benefits of participating in the study and have 
their questions answered. A copy of both of the consent forms will be given to each subject.  
 
All data collection for this study is now complete and no further participants will be recruited or 
enrolled. The data is being used in a manner to which the participants previously provided 
written consent and the original PI of the study is the individual requesting the data for purposes 
of data analysis and publication. 
 
 
E. 4. Potential risks. 
E. 4. 1. Cognitive testing: This is well tolerated by patients. Participants could become   tired 
or frustrated by the difficulty of the cognitive tasks. However, the cognitive testing will last only 
approximately 1.5 hours, which is a relatively short duration in comparison to similar IRB 
approved protocols. 
 
E. 4. 2. Neuroimaging:  
 
E. 4. 3. Lumbar punctures: The most common complication of lumbar puncture is post-dural 
puncture headache. The rate of headache occurrence can be reduced to as low as 1.7% with 
use of an atraumatic 21-gauge Sprotte spinal needle [108] with a very small gauge (25 gauge 
with introducer), and using a gentle extraction technique now widely used in AD research. 
Bacterial meningitis is a very rare complication of lumbar puncture, occurring in fewer than 0.2% 
in one series [109]. Uncal or tonsillar herniation is a very uncommon complication, occurring in 
<1% of very high-risk subjects with known primary or metastatic neoplasms who underwent a 
lumbar puncture [110]. Using a smaller (24-gauge) Sprotte needle in this trial, we anticipate a 
reduction in post-LP headache rates to 5% (from our current rate of 9.3%).  Only one of our 
previous subjects required a blood patch for the headache. Serious post-LP complications such 
as adhesive arachnoiditis are extremely rare, with estimates close to 0.4-0.6 per 10,000 
procedures [111]. Therefore, we do not anticipate such significant complications during the 
course of this study. Dr. Carlsson will perform a neurological and fundoscopic exam on each 
subject prior to lumbar puncture and those participants thought to have papilledema or gross 
neurologic deficits consistent with a central nervous system mass will not have a lumbar 
puncture performed. Each subject will be called the day following his or her lumbar puncture to 
ask about any side effects. All subjects will be given a telephone number to reach a physician 
24-hours per day.  
 
E. 4. 4. Social: The social risk is a breach of confidentiality regarding risk for development of 
AD. Subject names and research data will be handled with utmost confidentiality and discretion. 
Subjects will be assigned a unique identification number that can be traced only by the research 
coordinator and Principal Investigator. All subject information will be kept in locked drawers, file 
cabinets, or secure computer files, with access only allowed to research personnel. 
 
 
E. 4. 5. Ethical, Psychological, Legal, Other. Although participants will be given information 
on their plasma lipoprotein subclassification at the conclusion of their participation, they will not 
be given information about their APOE4 status, CSF or plasma biomarkers. This will be clearly 


 
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stated in the informed consent process. Although APOE4 allele is associated with a higher risk 
of developing AD, not all people with APOE4 develop AD and not all AD patients are APOE4 
allele carriers. Also, there are no clear standards in cognitively healthy adults for identifying 
higher risk individuals using CSF or plasma biomarkers. Furthermore, although these markers 
may predict who is at higher risk of developing AD, they are still in the research stages and do 
not have proven roles in clinical practice. In addition, since there are no established effective 
preventive therapies for AD, providing individuals with individual risk data may only add to their 
psychological burden and not provide them any benefit. If, during the course of the study, a new 
medication is approved by the FDA for AD prevention in high-risk individuals, then current 
policies will be revised to ensure good clinical care for study participants. Insurability of 
participants may be affected if there is any breach of confidentiality, which we do not anticipate.  
 
E. 5. Protection of Subjects. As stated above, the physical, social, and psychological risks 
associated with this study are small. Subjects will not be allowed to participate if their physician 
does not feel that it would be safe or prudent for them to do so. Subjects will be monitored for 30 
minutes after lumbar puncture and will be called the next day after the procedure to inquire 
about adverse effects. Confidentiality will be assured by assigning a unique subject number to 
each subject. All subject information will be kept in locked drawers, file cabinets, or secure 
computer files, with access only allowed to research personnel.  Data from this study may be 
shared with researchers of an associated protocol involving exercise and Alzheimer’s disease 
risk in the event that the subject consents to participate in the associated exercise protocol. All 
data and samples will be housed at UW Madison.  
 
 
E. 6.  Risks and expected benefits for subjects and society. As above, the risks associated 
with this study are small. Although individual participants may not derive clinically apparent 
cognitive benefits from ramipril during the course of the study, they may benefit from future 
research that builds on these data should ACE-I eventually be proven to have a role in AD 
prevention. Subjects will receive free fasting lipid profiles as part of this study. Subjects will 
receive honoraria to reimburse them for their time and effort.  
 
The benefits to society may be considerable. Society, specifically individuals at risk for AD, will 
benefit by learning if the markers indicating risk for cognitive decline can be modified by ACE-I 
therapy. This knowledge could affect decisions regarding initiation of ACE-I therapy for 
prevention of AD.  Since the completion of this study, the PI and others have conducted similar 
research showing the protective effects of RAS acting antihypertensives on multiple outcomes 
including hippocampal volume, cerebral blood flow, brain inflammatory markers, cognitive 
function and perhaps most importantly, reduced disease progression from MCI to AD over a 4 
year period.  
 
 
E. 7. Inclusion Report 
 
E. 7. 1. Inclusion of Women. All participants will be invited through clinic visits, recruitment 
registry or individual flyers to participate in this study. Since approximately 70% of AD cases are 
women, we expect that percentage to be reflected in our study population and we will 
emphasize the importance of AD prevention research in the context of women’s health to those 
invited to participate. 
 
 


 
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E. 7. 2. Pregnancy and Contraception: For women of child bearing potential, it is important to 
note that ACE inhibitors are labeled with a pregnancy ‘category D’ by the Food and Drug 
Administration (FDA). This means that there have been studies in pregnant women that show 
the drug was associated with some risk for the fetus during the 2nd and 3rd trimesters. Because 
of this, premenopausal females who have not had a hysterectomy must agree to use at least 
one form of contraception during the study, in addition to a male partner who correctly uses a 
condom or is sterile. The medically accepted methods of birth control to use while enrolled in 
the study are: 
- 
Oral contraceptives (either combined or progesterone only) 
- 
Intrauterine device (IUD) 
- 
Transdermal contraceptive patch 
- 
Injectable progesterone 
- 
Implants of levonorgestrel 
- 
Double barrier method: condom + cervical cap or diaphragm with spermicidal agent 
 
<http://www.fda.gov/CDER/drug/advisory/ACEI.htm> 
 
E. 7. 3. Inclusion of Minorities: Since enrollment in this study requires subjects to come to UW 
CTRC for testing, the registrant population is primarily from Dane County. According to the 2000 
Census, Dane County’s total minority population between the ages of 45 to 70 years was 3% of 
the population (see Table 2). Based on this statistic, we will attempt to enroll 1-2 minorities.  
 
Table 2. Dane County, Wisconsin, 2000 Census Data 
 
Number 
% 
Race/Ethnicity 
Ages 45-64 
Ages 45-64 
 White 
85,244 
93.7% 
 Black 
2,187 
2.4% 
 Hispanic 
1,291 
1.4% 
 Asian/Pacific Islander 
1,522 
1.7% 
 American Indian, Eskimo, or Aleut 
217 
0.2% 
 Other race 
560 
0.6% 
 
 
E. 8. Data Safety and Monitoring 
All participants will provide informed consent and the study will be overseen by a Data Safety 
and Monitoring Board (DSMB) consisting of a physician and statistician who are not directly 
involved in the study. Dr. Amy Kind is a physician who has served on DSMBs and has worked 
with the PI and Co-Is on previous projects. Similarly, Jodi Barnet MS, is a biostatistician who 
has also worked with the PI and Co-Is and has also been directly involved in clinical trials 
investigating the effects of statins on CSF Aβ and cognitive outcome variables. Additionally, Dr. 
Carlsson (Co-I) will serve on the DSMB and will be primary physician involved in this study. All 
side effects will be closely monitored. The most common side effects of ACE-I are mild cough, 
hyperkalemia or changes in kidney function. The most common side effect of lumbar puncture 
(LP) is headache, which is usually self-limited. At UW, the rate of headaches following LP is less 
than 5%. Dr. Carlsson will perform lumbar punctures for the proposed trial and has significant 
experience with this procedure, having performed over 260 lumbar punctures in the last five 
years with no complications. Participants will receive a phone call 24 hours after the LP to 
inquire about any post-procedure adverse effects. According to the Joint National Committee on 
Prevention (JNCP) VII guidelines, a dietary intervention for mild BP elevation for 4 months is 


 
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within the standard of clinical care [112]. All participants will receive wellness program 
information, which includes the DASH lifestyle intervention. Compliance will be measured via 
self report. Participants with contraindications to ACE-I therapy or LP will be excluded from 
participation. All subjects will be monitored for high blood pressure (systolic > 160 or diastolic > 
100) and other possible side effects at each visit. At each visit, participants will be screened with 
blood pressure readings, blood tests, possible pregnancy tests and questionnaires to inquire 
about potential side effects. Participants with elevated potassium or creatinine will be advised to 
stop treatment and will have follow up labs until the abnormalities resolve. Should a participant’s 
BP rise to unsafe levels (systolic > 160 or diastolic > 100) the participant will be advised to visit 
his/her primary care physician and the DSMB will be notified immediately. CSF collection will be 
completed according to guidelines put forth in the “NIA Biospecimens Best Practice Guidelines 
for the Alzheimer’s Disease Centers.”  Once enrollment has ended, the DSMB will no longer 
meet; however will be available on an as-needed basis. 
 
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ADRDA Work Group under the auspices of Department of Health and Human Services 
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3. Staessen, J.A., et al., Randomised double-blind comparison of placebo and active 
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neprilysin and endothelin-converting enzyme but not angiotensin-converting enzyme. J Biol 
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5. Hebert, L.E., et al., Annual incidence of Alzheimer disease in the United States projected to 
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