Conditions: Renal Insufficiency, Chronic
Keywords: Chronic Kidney Diseases Chronic Kidney Insufficiency Chronic Renal Diseases Chronic Renal Insufficiency Kidney Insufficiency, Chronic Cardiac Failure Congestive Heart Failure Heart Decompensation Heart Failure, Congestive Myocardial Failure
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 8
Healthy volunteers: no

Brief summary:
Heart failure (HF) is an epidemic and is a major burden on the US healthcare system. The most common cardiovascular endpoint is HF. Thus, novel interventions to prevent HF in chronic kidney disease (CKD) are highly desirable. This study will assess: the variability in the response to isosorbide mononitrate (ISMN) therapy; the degree of change in central hemodynamics and cardiac endpoints through analysis of changes in left ventricle (LV) mass, diffuse myocardial fibrosis, and myocardial systolic and diastolic function.

Detailed description:
This is a open label, parallel arm, randomized study of ISMN with or without vitamin C to improve exercise capacity and LV remodeling in CKD. Twenty subjects with CKD will be enrolled in this study and three different daily doses of sustained release isosorbide mononitrate (SR-ISMN) will be administered over time accompanied by a random administration of vitamin C in half of the subjects (500 mg three times daily). Before administration of SR-ISMN, baseline assessments will be performed. These include arterial tonometry, Doppler echocardiography, reflection magnitude measurements, a bicycle exercise test, activity monitoring, cardiac MRI, 24-hour blood pressure monitoring, and blood drawing. After these assessments, a dose of 30 mg of SR-ISMN will be administered daily (either with or without vitamin C) for the first week, 60 mg SR-ISMN for the second week, and 120 mg for the third week. After each week, blood pressure and central hemodynamics will be assessed. The third week visit also includes the bicycle exercise study and initiating the long term dose (60 or 120 mg) of SR-ISMN. In the long-term phase, blood pressure and hemodynamics are assessed at 12-weeks post initiation of the study medication(s). After 24 weeks we will perform the final assessment, which includes the same tests performed during the baseline assessment. Enrollment will take place at the Hospital of the University of Pennsylvania and the Penn Presbyterian Medical Center.

Arms:
arm 1: Patients receive only ISMN arm 2: Patients receive both ISMN and Vitamin C

Interventions: intervention 1: ISMN intervention 2: Vitamin C
Intervention descriptions: intervention 1: None intervention 2: None

Protocol document:
Prot_SAP_000.pdf: 
 
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PROTOCOL  
 
Targeting Central Pulsatile Hemodynamics in Chronic Kidney Disease 
 
 
NCT02791906 
 
Sponsor:  National Heart, Lung and Blood Institute (NHLBI) 
 
Principal Investigator:  Julio A. Chirinos, M.D., Ph.D. 
 
Co-Investigators 
 
Raymond Townsend, MD 
Alexandra Hanlon., Ph.D.  
Jesse Chittams, M.Sc. 
 
 
 
Data Coordinating Center:  
 
Alexandra Hanlon., Ph.D.,  Jesse Chittams, M.Sc. 
 
 
  
   
Version Date: February 15, 2016 
Version 03 
 
 
 


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A. SPECIFIC AIMS 
 
Heart Failure (HF) affects ~2% of the western population and ~10% of individuals aged 
>75 years. Not only is HF already an epidemic, but with the aging of the population, a 
dramatic further increase in its prevalence is expected. Given the enormous public health, 
clinical and societal burden of HF, finding effective prevention strategies for this condition 
is a top priority.  Patients with CKD are at a markedly increased risk of HF, which is a 
major cause of morbidity and mortality in this population1, 2. The Chronic Renal 
Insufficiency Cohort Study, which included a large population of patients with early CKD, 
demonstrated that the most common cardiovascular endpoint was HF.  Among 2,606 
CRIC participants without HF at baseline, during a mean of 3.5 years of follow-up, 154 
experienced new-onset HF.3  This occurred despite a mean baseline blood pressure of 
126/70 mmHg is this cohort.  Thus, given the high prevalence of CKD in the adult US 
population (estimated at 12-13%4) and the high risk of HF in CKD, novel interventions to 
prevent HF in CKD are highly desirable. 
Every heart beat, the left ventricle (LV) generates a pulse wave that travels forward 
in the arteries, gets partially reflected in the peripheral arterial tree and travels back to the 
heart, arriving while the LV is still ejecting blood. The reflected wave increases the late 
systolic workload of the LV. We will present substantial evidence that links the loading 
sequence (increased late systolic load) with the development of HF, diastolic dysfunction 
and LV hypertrophy independent of blood pressure levels. Therefore, wave reflections 
represent a potential therapeutic target to improve LV hypertrophy and diastolic 
dysfunction, and ultimately, the risk of HF in CKD. 
Wave reflections can be markedly reduced by organic nitrates, which dilate middle-
sized muscular arteries even at doses that do not substantially reduce brachial blood 
pressure. Our overarching hypothesis is that reducing arterial wave reflections with 
organic nitrates will reduce LV hypertrophy (a precursor to HF), fibrosis and improve 
myocardial function in subjects with CKD, independently of blood pressure reduction. Our 
ultimate goal is to perform an RO1-funded double-blind, parallel-arm, placebo-controlled 
randomized clinical trial that will enroll patients with CKD and randomize them to either 
sustained-release isosorbide mononitrate therapy (SR-ISMN) or placebo for 24 weeks.  
In this R56-funded study, we aim to obtain key preliminary data for an RO1 re-
submission to accomplish a phase IIb randomized controlled trial to test our hypothesis. 
We wish to obtain: (1) preliminary data regarding the variability in the change of our 
endpoints in response to our intervention in this specific population; (2) Preliminary data 
regarding the effects of ISMN on blood pressure vs. wave reflections at different doses; 
(3) Data supporting the feasibility and local expertise to implement a biomarker discovery 
approach using proteomics. Our specific aims are: 
 
PRIMARY AIMS: to assess the variability in the response and to perform a dose-response 
assessment in the degree of change in central hemodynamics and cardiac endpoints with 


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ISMN therapy in this population. We propose to administer 3 different doses of SR-ISMN 
(30, 60 and 120 mg of SR ISMN daily) to 20 subjects with CKD, in order to accomplish the 
following co-primary aims: 
1a. To assess the variability in the change in LV mass with ISMN administration (in order 
to support aim 1a of our eventual RO1-funded trial). LV mass will be measured with 
steady-state free precession cardiac MRI.  
1b. To assess the variability in changes in diffuse myocardial fibrosis with ISMN 
administration, using T1-mapping MRI techniques.5-12  
1c. To assess the variability in changes in myocardial systolic and diastolic function 
with ISMN administration, assessed via systolic strain (measured with displacement 
encoded MRI, DENSE) and early diastolic mitral annular velocity (measured with tissue 
Doppler echocardiography), respectively.  
 
 
SECONDARY AIMS:  
 
1) To establish the feasibility of reducing wave reflections while minimizing 
changes in brachial blood pressure. By performing assessments of the effects of 
3 different doses of SR ISMN on office and 24-hour blood pressure and wave 
reflections, we aim to determine which dose of this drug best reduces wave 
reflections with the least impact on brachial blood pressure in this particular 
population. This will directly support secondary aim 1 of the RO1 application and 
will inform about the best dose to use in the definitive RO1-funded trial/application. 
We will also assess whether vitamin C reduces the tolerance to nitrate therapy 
over time.  
 
2) We will gather preliminary data regarding the feasibility of using an unbiased 
biomarker discovery approach to identify biomarkers/pathways that change with 
ISMN administration in our 20 subjects. We will utilize a novel proteomic approach 
(Somascan) to measure levels of 1,129 candidate biomarkers at baseline and after 
ISMN. We eventually want to identify novel biomarkers/pathways that correlate 
with the cardiac response to ISMN.  
 
3) To assess the variability in changes in aerobic capacity (peak oxygen 
consumption during maximal supine bicycle exercise test), vasodilatory reserve 
to exercise (reduction in systemic vascular resistance with exercise, measured 
with Doppler echocardiography), and physical activity (assessed via actigraphy) 
with ISMN administration.  
 


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B. BACKGROUND AND SIGNIFICANCE  
 
Heart failure (HF) is a major epidemic. 
Heart Failure (HF) affects ~2.4% of the US 
population and 10% of individuals aged >75 
years. The burden of HF has increased 
dramatically over the last few years, vastly 
exceeding previous projections (Figure 1). 
According 
to 
the 
American 
Heart 
Association13, 14 the number of new HF 
cases in the US increased from 348,000 in 
2000 to 670,000 in 2007, representing a 
93% increase over this time period. Not only 
is HF already an epidemic, but with the aging of the population, a dramatic further increase 
in its prevalence is expected.  
 
Once established HF is a malignant disease, with  a high mortality rate, poor quality 
of life and a high burden on society: Once HF ensues, mortality is high, with 50% of 
Medicare beneficiaries not surviving 3 years after an HF hospitalization.15 Similarly, HF is 
associated with a markedly impaired quality of life.16-19  It has recently been estimated that 
yearly costs to treat HF will double to ~70 billion from 2012 to 2030,20 although direct costs 
could exceed $160 billion by 2030.20  
 
HF is the main cardiovascular outcome in chronic kidney disease (CKD): Patients 
with CKD are at an increased risk of HF, which is a major cause of morbidity and mortality 
in this population1, 2. We have participated in the NIH-funded Chronic Renal Insufficiency 
Cohort Study, which included a large population of patients with early CKD. In CRIC, the 
most common cardiovascular endpoint was HF.  Among 2,606 CRIC participants without 
HF at baseline, during a mean of 3.5 years of follow-up, 154 experienced new-onset HF 
(unpublished data; manuscript under peer-review).  This occurred despite a mean 
baseline blood pressure of 126/70 mmHg is this cohort.  Thus, given the high prevalence 
of CKD in the adult US population (estimated at 12-13%4) and the high risk of HF in CKD, 
novel interventions to prevent HF in CKD are highly desirable. 
 
In summary, HF in an epidemic and the most common cardiac complication in CKD. 
New cost-effective strategies are needed for the prevention of symptomatic HF in 
CKD. Such interventions should target processes upstream of the development of 
myocardial remodeling and dysfunction. A series of animal studies support the notion 
that increased arterial wave reflections (which increase the late systolic load of the LV) 
lead to myocardial remodeling, fibrosis and dysfunction. In addition, observational studies 
in humans have shown that increased wave reflections are associated with left ventricular 
remodeling, myocardial dysfunction and an increased risk of HF. Yet, human experimental 
studies (i.e., randomized controlled trials) are lacking to prove the causal effect of wave 
reflections and exploit wave reflections as a clinically-relevant therapeutic target. 
Increased wave reflections constitute a prominent feature of patients with CKD, which is 


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highly treatable. However, whether reducing late systolic load from wave reflections 
reduces maladaptive LV remodeling (a precursor of HF) is unknown. We wish to 
eventually perform a phase IIb randomized controlled double-blinded clinical trial to test 
this paradigm and address this knowledge gap. The trial would support a new 
pathophysiologic paradigm and identify a novel, inexpensive therapeutic intervention for 
HF prevention in CKD population. In order to propose a definitive trial, the NIH has 
awarded us a bridge grant, in order to generate preliminary data regarding dose-response 
and variability in study endpoints using nitrate therapy in CKD. 
Wave reflections in the arterial tree: Every heartbeat, the LV generates a pulse wave 
that travels forward in the arteries and gets partially reflected at sites of impedance 
mismatch, such as points of branching or change in wall diameter or material properties 
along the arterial tree. Wave reflections occur predominantly in the bifurcations in 
middle-sized muscular arterial segments21-23 and are conducted back to the heart, 
merging into a discrete reflected wave.21-23 The source of wave reflections is thus different 
from the resistance microvasculature, which determines mean arterial pressure.21-23 
 
The reflected wave affects LV afterload and alters the loading sequence. Due to the 
wave transit time from the heart to reflection sites and back to the proximal aorta, wave 
reflections arrive back at heart while the LV is still ejecting blood in mid-to-late systole.23, 
24 Wave reflections thus increase the late systolic workload of the LV and profoundly 
impact the LV loading sequence (late relative to early systolic load).  


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Late systolic loading from wave reflections promotes LV hypertrophy in rats. For 
any given level of systolic (peak) blood pressure, prominent late-systolic loading has been 
shown to exert deleterious effects on LV structure and function in animal models.23, 25, 26 
Kobayashi et al25 used a Wistar rat model and performed constriction of either the 
ascending aorta (intervention A, top left and middle panels in Figure 2) or suprarenal 
abdominal aorta (intervention B, bottom left and middle panels in Figure 2). Analysis of 
aortic input impedance (which represent the mechanical pulsatile load that the arterial tree 
imposes on the LV; not shown in Figure 2) demonstrated that constriction of the ascending 
aorta increased LV load in early systole, whereas constriction of the descending aorta 
caused prominent late systolic loading from a reflected wave that originated at the distal 
aortic constriction site, arriving at the heart in late systole.25 The middle top and bottom 
panels in figure 2 show an example of the LV pressure profile induced by proximal aortic 
constriction (early systolic peak) and descending aortic constriction (late systolic peak), 
respectively. The 2 bar graphs on the right of figure 2 show peak LV pressure and LV 
mass in rats subjected to ascending aortic constriction (hollow blue arrows), descending 
aortic constriction (solid red arrows) and sham interventions (no arrows). It can be seen 


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that, despite an identical peak LV pressure in rats that underwent ascending vs. 


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descending aortic constriction (top right panel in figure 2), rats that underwent descending 
aortic banding (and were thus exposed to greater late systolic load) demonstrated much 
greater LV hypertrophy than those undergoing ascending aortic banding (which were 
exposed to increased early systolic load) (right bottom panel in figure 
 
 2). Rats that underwent descending aortic  
banding also demonstrated a greater amount of myocardial fibrosis25 (not shown).  
 
To date, we have only observational data in humans supporting these causal findings.  
 
 
Since our initial application, we have published a study demonstrating an independent 
association between reflected wave amplitude an LV hypertrophy in the general 
population.27 Furthermore, Hashimoto et al28 reported an observational study in which the 
reduction in wave reflections correlated with regression of LV mass independently of blood 
pressure reduction. The association between reflected wave magnitude reduction and LV 
mass (i.e., hypertrophy) reduction was also independent of age, sex, and use of renin-
angiotensin system inhibitors (β=0.41, P=0.001). Of note, despite the fact that standard 
antihypertensive therapies reduce wave reflections in some patients (those on the 
negative side of the x axis in figure 3), the change is highly unpredictable, with reflection 
magnitude actually increasing in some subjects (see those demonstrating a positive 
change in the x axis of Figure 2). In contrast, organic nitrates consistently and markedly 
blunt wave reflections, which occurs at doses that do not cause significant changes in 
brachial blood pressure (see also our preliminary data in CKD regarding the lack of 
changes in brachial BP).29, 30 Of note, organic nitrates are not part of the routine therapy 
for CKD or hypertensive patients. Similarly, the paradigm of targeting wave reflections with 
therapy has not been implemented in clinical practice due to the lack of: (a) experimental 
data proving a cause effect relation between wave reflections and LV hypertrophy / failure 
and; (b) Efficacy data for organic nitrates for this purpose. Late systolic load promotes 
diastolic dysfunction in humans Gillebert et al 31  used a canine model to study the 
effect of the timing of systolic load on LV relaxation by inflating balloons in the ascending 
aorta during either early vs. late systole. Their study demonstrated that, for a given 
increase in peak (systolic) LV pressure, late systolic inflation (triangles in figure 3) 
prolonged tau (i.e. impaired LV relaxation assessed with the gold standard measure) much 
more than early systolic inflation (circles in figure 3), demonstrating that late systolic load 
can lead to diastolic dysfunction.31 In support of these findings, cross-sectional 
observational studies in humans have independently linked wave reflections and late 
systolic load to diastolic dysfunction in humans.32, 33 Recently, we developed a non-
invasive technique to characterize the time course of LV systolic wall stress in humans, 
by 
means 
of 
assessing 
time-resolved 
LV 
geometry 
with 
speckle-tracking 
echocardiography and time-resolved central pressures using carotid arterial tonometry.34 
In 2009, we published our first characterization of time-resolved LV wall stress in 
normotensive and hypertensive humans.34 A time-resolved stress curve can be used to 
separate early and late systolic wall stress (i.e., early vs. late myocardial systolic load), 
which can be quantified as the area under the time-resolved stress curve (stress-time 
integral, STI) in the first and second halves of ejection, respectively (figure 5). More 


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recently35, 36 we applied this technique to a large population-based study (Asklepios study), 
in which we have collaborated over the last few years.34, 36-39 We assessed the relationship 
between the myocardial loading sequence (early vs. late wall stress) and diastolic 
function.35 After adjustment for multiple covariates, late systolic load was independently 
associated with lower mitral annular relaxation velocities, in sharp contrast to early systolic 
load which was associated with higher mitral annular relaxation velocities, in a multivariate 
model (Table 1), implicating the loading sequence as an independent correlate of 
myocardial relaxation in humans. This model explained 46% of the variability in mitral 
annular diastolic (relaxation) velocity. However, available observational data in humans 
cannot prove a causal relationship between late systolic load and diastolic dysfunction 
and this approach is not currently applied clinically in patients with diastolic dysfunction.  
The magnitude of wave reflections strongly predicts new-onset  HF. Based on the 
data presented above, we hypothesized that wave reflections can predict new-onset HF 
in the general population. To test this hypothesis, we derived aortic pressure waveforms 
using a transfer function applied to the radial waveform recorded at baseline with arterial 
tonometry from 5,934 participants in the Multiethnic Study of Atherosclerosis, who were 
free of clinically apparent cardiovascular disease. The central pressure waveform was 
used to assess reflection magnitude.40, 41 During 7.61 years of follow-up (and after 
adjustment for blood pressure, age, gender, body mass index, diabetes, ethnicity, 
antihypertensive medication use, total and HDL-cholesterol, current smoking, heart rate 
and glomerular filtration rate), reflection magnitude strongly predicted HF (Hazard ratio 
per 10%-increase = 2.69; 95%CI = 1.79-4.04;  P<0.0001) and was a stronger predictor  
than blood pressure and all other modifiable risk factors listed above.  
When we stratified the population based on the presence or absence of hypertension and 
the presence or absence of high reflection magnitude (Figure 6), we found that, compared 
to non-hypertensive subjects with low reflection magnitude (lowest risk category), hazard 
ratios for hypertensive subjects with low reflection magnitude, non-hypertensive subjects 
with high reflection magnitude and hypertensive subjects with high reflection magnitude 
were 1.81, 2.16 and 3.98, respectively (95%CIs are shown in Figure 6). 
 
 


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Furthermore, we compared the strength of the association between reflection magnitude 
and incident HF using multiple parameters, including standardized hazard ratios, c-
statistics and measures of model fit (Akaike’s information criterion, Bayesian information 
criterion). We also assessed the incremental information provided when various predictors 
were added to a model containing all other predictors of heart failure, in terms of 
discrimination 
(integrated 
discrimination 
improvement) 
and 
reclassification 
(net 
reclassification improvement). 
Reflection 
magnitude 
was 
associated with the largest 
Wald statistic of all predictors 
(including age), the greatest 
reduction 
in 
Akaike’s 
information 
and 
Bayesian 
information criteria (indicating 
improvement in model fit) and 
the 
greatest 
increases 
in 
integrated 
discrimination 
improvement (with a 48% 
increase 
in 
discrimination 
slope 
achieved 
when 
reflection 
magnitude 
was 
added to a base model 
containing all other predictors 
of 
HF 
and 
multiple 
confounders listed at the bottom of Table 2). With the exception of age, a non-modifiable 
risk factor, reflection magnitude was associated with the greatest net reclassification 
improvement for prediction of HF.  Therefore, reflection magnitude was the most robust 
and strong independent modifiable predictor of incident HF.   More recently we 
demonstrated that, for any given level of systolic and diastolic blood pressure and various 
other risk factors and confounders, a greater area under the pressure curve in late systole 
(relative to early systole) is strongly predictive of incident HF in the same cohort.42 Our 
findings from these studies in a large community-based sample with careful follow-up and 
event adjudication, implicate late systolic load from arterial wave reflections as a novel 
strong predictor for the risk HF, Based on the strength of this prediction, a high reflection 
magnitude has been proposed to represent a novel form of stage B HF.41 Yet, although 
available data clearly implicate late systolic load from arterial wave reflections as a novel 
marker of the risk of HF, available data do not prove a causal role in humans. We believe 
that the strong biologic plausibility (based on animal models) and the supportive human 
observations support the need for a randomized controlled trial specifically designed 
to test this paradigm. The lack of such data is a major gap in the field and in the 
translation of the paradigm to human therapeutics. We aim to fill this knowledge gap, which 
would significantly advance the field. Furthermore, If the remarkably strong association 
demonstrated between wave reflections and HF is causal, then targeting wave 
reflections could provide large reductions in HF-related morbidity and mortality, a 


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highly desirable goal from the clinical and public health perspective. In order to design a 
definitive proof of concept trial, we must first establish the optimal dose of ISMN to reduce 
wave reflections independently of blood pressure and to assess the variability in study 
endpoints in response to ISMN in this particular population, such that adequate power 
calculations can be made.  
 
C. RESEARCH DESIGN AND METHODS 
 
C.1. Overview of study design 
 
This is a pilot study in which we will study 20 subjects with CKD. We will perform a run-in 
phase in which the dose of sustained-release ISMN (SR-ISMN) will be increased from 30 
to 120 mg over weeks. We will administer 30 mg for 1 week, followed by 60 mg for 1 week, 
followed by 120 for 1 week. At the end of each week, we will perform detailed assessments 
of blood pressure and central hemodynamics. We will assign half of the participants to 
receive vitamin C (500 mg three times daily) to assess whether this intervention reduces 
nitrate tolerance.  
After the initial 3-week run in phase, we will randomly assign subjects to receive either 60 
or 120 mg of SR-ISMN for additional 21 weeks (for a total of 24 weeks of therapy). Half of 
the subjects will continue to receive vitamin C (500 mg three times daily by mouth) 
throughout this 21-week period. We will assess the effect of our interventions on late 
systolic load, LV mass, LV fibrosis, diastolic relaxation and quality of life. 
After subjects are identified and demonstrate an interest in the research study, inclusion 
and exclusion criteria will be assessed and if eligible, the patients will undergo written 
informed consent and enrolled in the study.   
 
C.2 Study Sites 
 
The two sites for this trial will be the Hospital of the University of Pennsylvania and the 
Penn Presbyterian Medical Center. Both sites share a single Institutional Review Board.  
 
C.3. Study Population 
 
Subjects will be recruited from referrals as well as medical record searches (PennSeek). 
We will enroll adults (age 18 or older) who meet the following criteria: 
Inclusion criteria: (1) Chronic kidney disease stage 3 (defined as an estimated 
glomerular filtration rate [GFR] of 30-59 ml/min/1.73m2), estimated by the CRIC GFR 
equation43 (2) An elevated left ventricular mass index (defined as >60 g/m1.7 in women 
and 80 g/m1.7 in men)38 or LV posterior wall thickness44 >1.4 cm documented in a clinically 
indicated echocardiographic or MRI examination within the previous 24 months; (3) Stable 
medical therapy as defined by no addition, removal or change in dosage >100% of ACE 


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inhibitors, angiotensin receptor blockers, beta-blockers, or calcium channel blockers for 
>30 days; (4) Current therapy with an ACE inhibitor, hydralazine or a statin, all of which 
have been shown to reduce nitrate tolerance. 45-53 
 
Exclusion Criteria: (1) A clinically- indicated stress test demonstrating significant 
myocardial ischemia within 1 year of enrollment, not followed by coronary 
revascularization; (2) Rhythm other than sinus (i.e., atrial fibrillation); (3) Non-cardiac 
condition limiting life expectancy to <1 year; (4) Current or anticipated future need for long 
acting organic nitrate therapy; (5) Severe aortic or mitral valve disease; (6) Hypertrophic 
cardiomyopathy; (7) Known infiltrative or inflammatory myocardial disease (amyloid, 
sarcoid); (8) Pericardial disease; (9) Primary pulmonary arteriopathy; (10) History of 
myocardial infarction, unstable angina, percutaneous transluminal coronary angiography 
(PTCA) or coronary artery bypass grafting (CABG) within 60 days, or requirement for 
either PTCA or CABG at the time of consent; (11) Resting heart rate (HR) >100 bpm: (12) 
A reduced LV ejection fraction (EF<50%); (13) Known severe liver disease (AST >3x 
normal, alkaline phosphatase or bilirubin >2x normal); (14) Allergy to ISMN; (15) Current 
therapy with phosphodiesterase inhibitors, such as sildenafil, vardanafil or tadalafil, since 
the combination of ISMN and phosphodiesterase inhibitors can result in severe 
hypotension; (16) Therapy with rosiglitazone, since its combination with ISMN is not 
recommended; (17) Current pregnancy or a positive urine pregnancy test; women who 
become pregnant during the study will be discontinued from the trial; (18) Therapy with 
warfarin (as vitamin C may interact with warfarin):54, 55 (19) History of kidney stones (as 
vitamin C may increase the excretion of oxalate); (20) History of G6PD deficiency (as 
vitamin C may precipitate hemolysis in these patients);54, 55 (21) Systolic blood pressure 
<110 mmHg or diastolic blood pressure <40 mmHg;  (22) Contraindications to a cardiac 
MRI: (a) Central nervous system aneurysm clips; (b) Implanted neural stimulators; (c) 
Implanted cardiac pacemaker or defibrillator; (d) Cochlear implant; (e) Ocular foreign body 
(e.g. metal shavings); (f) Other implanted medical devices: (e.g. drug infusion ports); (g) 
Insulin pump; (h) Metal shrapnel or bullet; (i) Claustrophobia; (j) Extreme obesity rendering 
the patient unable to fit into narrow-bore scanners; (k) Unwillingness of the patient to 
undergo a cardiac MRI.   


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C.4. Baseline assessments 
 
Arterial tonometry: We will use a commercially available system (SphygmoCor, AtCor 
Medical) that uses a high-fidelity applanation tonometer (Millar Instruments; Houston, 
TX).23 The tonometer will be used to record carotid, radial and brachial arterial pressure 
waveforms. Brachial systolic and diastolic pressures will be measured with a validated 
oscillometric device. Brachial diastolic and mean pressures will then be used to calibrate 
the carotid pressure waveform.56 Carotid-femoral and carotid-radial pulse wave velocity 
measurements will be performed. Heart to ankle and heart to femoral PWV will also be 
measured using a VaSera device (Fukuda Denshi; Tokyo, Japan), which uses inflatable 
cuffs around the thighs, ankles and arms and a phonocardiographic signal to assess the 
timing of the pulse at the heart, the femoral artery and the posterior tibial artery. 
 
Doppler echocardiography: will be performed with pulsed-wave Doppler interrogation of 
flow velocities in the LV outflow tract, mitral inflow and mitral annular velocities. Flow 
volume will be computed by multiplying LV outflow tract flow velocity by the LV outflow 
tract cross-sectional area measured with 3D echocardiography.21, 22  
 
Reflection magnitude will be computed using linear wave separation analysis21, 22, 56, 57 
using central pressure and flow waveforms measured via arterial tonometry and Doppler 
echocardiography, respectively.21, 22 
 
Bicycle Exercise Test: This is a test in which the subject will ride a special bicycle while 
lying on his/her back. We will ask the subject to ride the bike as long as possible, then 
rest, then ride the bike again for an additional 6 minutes. During each exercise event, the 
subject will breathe through a mouthpiece to measure oxygen consumption and CO2 
production. The length of this test will vary based on their exercise capacity. This will occur 
during the baseline assessment, at the end of the titration phase (3 weeks) and at the end 
of the long-term phase (24 weeks).  
 
Activity Monitor: Patients will be given an activity monitor to wear during the length of 
the titration phase, and then for 2 weeks prior to the 12- and 24- week visits (for the latter, 
the device will be mailed to the subjects 2 weeks prior to the study visit). This device, 
manufactured by ActiGraph, is a portable, wearable, activity monitor that subjects can 
wear around their belt. The device records activity information such as the number of steps 
taken and intensity of the physical activity.  
 
Cardiac MRI: The cardiac MRI protocol will include true-FISP cine acquisitions of the LV 
for assessment of LV mass. We will assess diffuse myocardial fibrosis by assessing the 
extracellular volume fraction, computed with the post-gadolinium (0.1 mmol/kgDotarem ) 


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normalized myocardial 1/T1 change and the blood 1/T1 change, after correction for 
hematocrit.58, 59 T1 mapping will be performed using a modified Look-Locker inversion 
recovery (MOLLI)60-62 with image analysis using CMR42 software (CVI42; Canada) and 
QMass software (Medis Medical Imaging Systems, The Netherlands. 
 
24-hour blood pressure monitoring: will be performed as using a MobileOGraph device 
(APC cardiovascular, London, UK) or an Oscar 2 device (SunTech Medical) which 
measures time-resolved brachial arterial pressure estimates arterial wave reflections in an 
ambulatory fashion based on analysis of the brachial pressure waveform obtained with a 
cuff. This test will be used to assess potential increases in wave reflections in the nitrate-
free period over the nighttime. The Oscar 2 device is FDA approved, but we will use a 
more advanced version of the device that can record the time-resolved pulse wave from 
the cuff while blood pressure is being taken. This particular use of the cuff is not FDA 
approved at present, but we won’t be used to guide any clinical decision making. We will 
also use a novel watch device produced by Microsoft (which is not yet commercially 
available or FDA-approved), which continuously measures the radial pulse via a mounted 
tonometer. The device also measures transit time from the heart to the wrist in an 
ambulatory fashion.  
 
Blood Draw: Blood samples will be obtained in order to measure serum creatinine and 
hematocrit prior to each cardiac MRI. In addition, samples will be centrifuged and frozen 
at -80 degrees C to perform proteomics analysis using the Somascan platform, which 
measures ~1300 plasma proteins. We will also collect a spot urine sample (~50 cc) in 
every study visit.  
C.5. Run-in phase and ISMN initiation  
 
Subjects will first undergo a run-in phase to assess within subject responses to ISMN at 
doses of 30 mg, 60 mg and 120 mg daily (with or without ascorbic acid), which will be 
better powered than between-arm comparisons. Half the subjects will be randomly 
assigned to receive ascorbic acid (500 mg by mouth three times daily).  
 
- 
After baseline assessments, ISMN will be initiated at a dose of 30 mg daily (with 
our without ascorbic acid). 
- 
1-week visit: Subjects will undergo a brief visit for peripheral, central BP and 
arterial stiffness measurements (arterial tonometry and VaSera device 
measurements) after ~1 week (5-9 days). ISMN will be increased to 60 mg daily. 
Blood (20 cc) and urine (~50 cc) will also be sampled and frozen.  
- 
2-week visit: Subjects will undergo a brief visit for peripheral, central BP and 
arterial stiffness measurements (arterial tonometry and VaSera device 


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measurements) after ~1 week (5-9 days). ISMN will be increased to 120 mg 
daily. Blood (20 cc) and urine (~50 cc) will also be sampled and frozen. 
- 
3-week visit: Subjects will undergo a brief visit for peripheral, central BP and 
arterial stiffness measurements (arterial tonometry and VaSera device 
measurements) after ~1 week (5-9 days). Subjects will also undergo a Doppler 
echocardiogram during this visit. A 24 hour ambulatory BP monitoring Blood (20 
cc) and urine (~50 cc) will also be sampled and frozen. 
 
In all cases, up-titration will occur only if:  
(1) Resting supine systolic blood pressure is ≥95 mmHg;  
(2) There is no evidence of orthostatic hypotension (decrease ≥20 mmHg in systolic or 
≥10 mmHg in diastolic blood pressure within 3 minutes of standing);63  
(3) The subject is not experiencing dizziness, vertigo, or other symptoms that, in the 
opinion of the investigator, may be due to the vasoactive effect of the drugs.  
 
If the drug is not tolerated, subjects will be discontinued from the study. After completion 
of the run-in phase, subjects will be assigned to different doses of SR-ISMN (60 and 120 
mg of SR ISMN daily) for additional 21 weeks (10 subjects per dose). Patients will continue 
taking ascorbic acid according to their initial allocation to receive or to not receive vitamin 
C. The design will therefore be a 2x2 factorial, such that 5 subjects will be allocated to 
ISMN SR 60- mg without vitamin C, 5 subjects will be allocated to ISMN SR 60- mg with 
vitamin C, 5 subjects will be allocated to ISMN SR 120- mg without vitamin C, and 5 
subjects will be allocated to ISMN SR 120- mg with vitamin C. The intervention will be 
open label, but endpoint assessments will be blinded.  
 
C.6. 12-week visit 
The 12-week visit will take place in which we will perform: 
- 
An office BP measurement 
- 
Arterial tonometry and VaSera measurements 
- 
A 2d Echocardiogram 
- 
24 hour ambulatory BP monitoring and pulse wave analysis monitoring 
- 
A blood draw and urine sample 
 
C.7. Final (24-week) assessments: 
 
After the end of the 24 weeks therapy, arterial tonometry, VaSera measurements, Doppler 
echocardiography, cardiac MRI, 24-hour BP / pulse wave analysis monitoring, and blood 
draws will be repeated after the end of 21 weeks of fixed dose ISMN SR therapy (with or 
without vitamin C), to assess for changes in response to the study intervention. 
Procedures will be identical to those performed during the baseline assessment. 
 
C8. Adverse Event Reporting 


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All adverse events will be reported following institutional guidelines. The research team 
will keep a log of all adverse events that occur in the trial, and any reportable events will 
be handled accordingly. The study team in charge of the conduct of the trial is up to date 
on all trainings pertaining to safety guidelines and adverse event reporting. All Serious 
Adverse Events will be reported to the site review boards, the Data Safety Monitoring 
Board, as well as the NIH in a timely fashion.  
 
C.7. Data Management 
 
The data for this trial will be collected by the research staff during each visit that the subject 
attends. Specific forms have been developed for the questions in this trial and will be filled 
out via pen and paper. Later, this data will be entered into a database developed in 
RedCap.  
 
All data collected in this trial will be housed inside of a locked cabinet in the office space 
of the research staff, located at Ravdin 2 (Cardiovascular Institute).  
 
C.8. Early termination 
 
Subjects who withdraw due to intolerable adverse events or other safety concerns, or 
simply because they no longer wish to participate in the trial, will undergo a termination 
visit in which we will document: (1) vital signs; (2) compliance with the medications, 
including pill count; (3) Adverse effects. (4) specific reason for withdrawal. 
 
D. Statistical Considerations 
 
All study outcomes are continuous measures, thus, least-square regression models will 
be used to estimate effect sizes associated with each intervention. For the run-in phase, 
we will used mixed models to assess within subject changes to 30- 60 and 120 mg, and 
also to assess the effect of ascorbic acid on this response.  
Analysis of the changes at 24 weeks between the study arms will also be assessed with 
mixed models to assess the following: (1) whether there are any significant within group 
changes in the outcome measures (from baseline to the final visit) in response to nitrate 
therapy at 30, 60 or 120 mg; (2) To test whether the outcome improvement in response to 
combination therapy is different between the 2 doses; (3) Whether vitamin C appears to 
have any effect on the responses. We recognize that this is a pilot study and therefore we 
will pay particular attention to the variability in the response and will interpret trends 
conservatively, particularly when confidence intervals are wide enough to be inconclusive. 
We note that, even through there is limited power for the inferential analyses, the data 
from this study will be critical to perform power calculations and propose a definitive trial, 
as per the aims of our R56 award.  MRI endpoints will involve only 2 measures (baseline 


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and 24-weeks). However, echocardiographic and tonometry measures will involve three 
measurements per subject during the long-term phase (baseline, 12-week and 24-week 
visit). These will be modeled for intervention effects using general linear modeling on the 
intent-to-treat population.64, 65  Subject-specific intercepts and slopes will be included as 
random effects; variability in the actual timing of assessments will be explicitly included in 
the mixed model by analyzing time as a random effect. Individual growth parameters will 
be modeled as a function of group, time, and the interaction of group and time. Differences 
in reflection magnitude over time will be examined via inferential testing of the “group by 
time” interaction term. Restricted maximum likelihood estimation will be used, and an 
appropriate covariance matrix will be specified.  Linear and quadratic mixed models will 
be examined. The Akaike information criterion66 will be used to evaluate overall model fit 
and to select the best-fitting longitudinal change pattern. For dropouts, the mechanism for 
missingness will be evaluated. If the number of subjects lost to follow-up is small and the 
missing observations can be documented as being missing at random (MAR) or missing 
completely at random (MCAR), analyses will be performed using the complete observed 
data. More complex approaches will be considered, such as random pattern-mixture 
models if necessary.67, 68 Sensitivity analyses for these models will be performed.69 We 
will use parsimonious linear models to assess whether the reduction in reflection 
magnitude predicts the improvement in individual outcomes (LV mass, LV collagen 
volume fraction, LV diastolic relaxation velocity). Bootstrapping procedures will be used to 
obtain estimates of the effects and to test their significance via confidence intervals.70  
Analyses will be 1-tailed since we hypothesize specific directions to the relationships or 
changes in measured parameters between baseline and 24 weeks post-initiation of long-
term therapy. 
 
F. PROTECTION OF HUMAN SUBJECTS 
F.1. RISKS TO THE SUBJECTS  
Human Subjects Involvement and Characteristics  
The conduct of these studies will involve 20 human subjects. All subjects will be adults 
able to give informed consent. Subjects will be enrolled without regard to gender or race. 
However, an effort will be made for an enrolled population composed of at least 50% 
females and ~50% members of an ethnic minority according to the demographic 
characteristics of the Philadelphia area. Children will not be enrolled. All patients will be 
recruited from the Hospital of the University of Pennsylvania or the Penn Presbyterian 
Medical Center. The study involves various tests (cardiac MRI with gadolinium, arterial 
tonometry, ambulatory blood pressure / pulse wave analysis measurements, a blood 
draw) and the administration of ISMN and ascorbic acid therapy. 
Potential Risks: There is minimal risk to the subjects. Potential risks are associated with 


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the study tests, the study interventions (pharmacologic therapy) and potential breaches in 
confidentiality.  
(1) Cardiac MRI: The non-invasive nature and the lack of ionizing radiation make the risks 
associated with MRI small. A MRI scan requires the participant to be in a partially 
enclosed space inside the scanner.   Some people may find this to be uncomfortable. 
Claustrophobia is an exclusion criterion for the study. The MRI scanner produces 
different types of noises during a scan. Participants are special earplugs to reduce the 
noise. A MRI scanner has a strong magnet which attracts certain metals. If anyone 
has these types of metal in their body, the MRI’s strong magnetic field can cause them 
to move which may cause injury. Subjects with be thoroughly screened for the 
presence of body metal and excluded from the study if they are unable to safely 
undergo a cardiac MRI.  
 
(2) Administration of gadolinium contrast: Gadolinium-based contrast agents may 
cause allergic reactions. In patients with advanced chronic kidney disease, these 
compounds may cause an extremely rare potentially fatal skin disease called 
nephrogenic systemic fibrosis. We will exclude subjects with advanced chronic kidney 
disease in this study (estimated glomerular filtration rate <30 mL/min/1.73 m2). There 
have only been two case reports of gadolinium-related nephrogenic systemic fibrosis 
in the 30-60 mL/min/1.73 m2 range (UpToDate accessed February 8, 2012).  The 
nephrologic investigator (Townsend) has reviewed and approved this aspect; 
Townsend has also conducted studies of gadolinium in CKD (Townsend RR et al. 
Safety of intravenous gadolinium (gd-bopta) infusion in patients with renal 
insufficiency. Am J Kidney Dis. 2000; 36:1207-1212). Chirinos routinely performs 
contrast-enhanced cardiac MRIs and has also approved this aspect, which is 
consistent with the routine clinical use of gadolinium-based compounds.  
 
(3) Phlebotomy carries minimal risk of infection and temporary pain.  
 
(4) Arterial 
tonometry 
(Sphygmocor) 
and 
cuff-based 
arterial 
stiffness 
measurements (VaSera) is non-invasive and does not have any known risks.  
 
(5) Study medications:  
 
a. ISMN at the doses that will be used in this study has a long track record of 
safety. There are possible risks or discomforts related to the study medication. 
The most common side effects of ISN are headache and mild dizziness, which 
tend to resolve or improve spontaneously even with continued intake. Side 
effects may also include warmth, redness, or tingly feeling under the skin. 
Some people have allergic reactions to this medication but this is very rare.   


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• 
Ascorbid acid: Vitamin C, also known as ascorbic acid, is available over the 
counter. Some studies have shown that higher blood levels of vitamin C are 
associated with lower risk of death from all-causes, cancer, and cardiovascular 
disease.54, 55, 71 In patients with diabetes, some studies suggest that vitamin C 
supplementation reduces the risk, whereas others suggest that it increases the 
risk, of cardiovascular disease.54, 55, 71 Despite the multiple studies, there is no 
evidence that vitamin C supplements exert benefit in this patient population. 
However, there is no evidence of harm, with excellent tolerability with doses up to 
2-10 grams/day in adults) exert any adverse or toxic effects. An upper level of 2 
grams/day is recommended in order to prevent some adults from experiencing 
diarrhea and other gastrointestinal symptoms. In this study, we will use a dose of 
500 mg three times daily, which is below this dose. Potential risks of discomforts 
include diarrhea, nausea, vomiting, heartburn, stomach cramps and headache. 
Such symptoms are not generally serious. Vitamin C may interact with warfarin, 
may increase the risk of oxalate kidney stone recurrence and may precipitate 
hemolysis in patients with glucose-6-phosphate dehydrogenase (G6PD) 
deficiency.72 Patients with either of these conditions will be excluded from the 
study. If patients experience any gastrointestinal symptoms or intolerance to 
vitamin C, we will reduce the dose to 500 mg bid, or 500 mg once daily. If vitamin 
C is still not tolerated, we will discontinue vitamin C, but subjects may remain in 
the trial taking only the assigned dose of ISMN-SR.  
 
(6) Ambulatory blood pressure monitoring may cause discomfort in the arm during cuff 
inflations but no serious risks are associated with this procedures. Ambulatory pulse 
wave analysis (Aurora device) may cause mild discomfort in the wrist. 
 
(7) During various procedures (cardiac MRI, echocardiography), we will use adhesive 
electrodes attached to the participant’s skin to record the electrical signal from the 
heart. These may occasionally cause skin itching and irritation. 
 
(8) As with any clinical research study, there is a potential for breach of confidentiality. 
Adequate measures will be taken to minimize this risk (below). 
 
These potential risks have been thoroughly considered and adequate protective measures 
will be implemented in the study (please see below).  
F. 2. ADEQUACY OF PROTECTION AGAINST RISKS  
a. Recruitment and Informed Consent: Written informed consent will be obtained from 
the subjects by the investigators prior to entry into the research study. This will be 
performed in accordance with the guidelines and under the supervision of the University 


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of Pennsylvania Institutional Review Boards. The study procedures and interventions and 
the associated risks will be explained to the subjects during the informed consent process. 
Only IRB-approved consent forms and related materials will be used. 
b. Protection against risks associated with the cardiac MRI: Subjects with be 
thoroughly screened for the presence of body metal and excluded from the study if they 
are unable to safely undergo a cardiac MRI. We will exclude patients who are not suitable 
candidates for a cardiac MRI by virtue of having the following absolute or relative 
contraindications: (i) Central nervous system aneurysm clips; (ii) Implanted neural 
stimulators; (iii) Implanted cardiac pacemaker or defibrillator; (iv) Cochlear implant; (v) 
Ocular foreign body (e.g. metal shavings); (vi) Other implanted medical devices: (e.g. drug 
infusion ports); (vii) Insulin pump; (viii) Metal shrapnel or bullet; (ix) Claustrophobia; (x) 
Extreme obesity rendering the patient unable to fit into narrow-bore scanners; (xi) 
Unwillingness of the patient to undergo a cardiac MRI. All patients with metallic implants 
will be individually evaluated prior to MRI.  Women with child-bearing potential will have a 
serum pregnancy test to exclude pregnancy immediately before study participation. 
Pregnant women will be excluded. Screening for MRI-related exclusion criteria will done 
during a phone interview (pre-screen) and with an on-site questionnaire at the time of 
the scan.    
 
Once subjects are deemed able to safely undergo a cardiac MRI, these will be 
performed according to standard safety practices as per our institutional standards. 
Voice contact with patients will be maintained throughout the scan. A crash cart is 
available and a code team can be deployed immediately should serious allergic 
reactions to gadolinium contrast occur. 
All cardiac MRIs will be interpreted clinically by Dr. Chirinos and by a board-
certified radiologist for incidental findings. Any incidental findings will be reported to the 
patient and at their request/approval, to their primary care physician. 
 
c. Protection against risks associated with gadolinium contrast: Serum creatinine 
will be measured prior to each scan to assure adequate renal function for the 
administration of gadolinium-based contrast as per our inclusion/exclusion criteria. 
Pregnancy status will be determined for all women of childbearing age before enrollment 
and before the final MRI scan. Pregnant women will be excluded and/or discontinued 
from the study. Subjects will not receive two injections of gadolinium within one week of 
each other as frequent use of gadolinium can cause nephrogenic systemic fibrosis 
(NSF). If a subject has recently received an MRI for clinical purposes, the research MRI 
will be delayed to avoid the second injection of gadolinium within the one week- 
timeframe.  
d. Protection against risks of study medications:  To reduce the risk of hypotension 
and related side effect, participants will be instructed to get up slowly when rising from a 
sitting or lying position. The study team will specifically assess for the presence of 


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hypotension and orthostatic hypotension, as well as symptoms such as dizziness after the 
medication is initiated or after the dose in increased, in order to determine whether it is 
safe for participants to continue taking these medications, or to uptitrate the dose. If 
participants find these side effects too uncomfortable, they will be deemed intolerant to 
the drugs and discontinued from the study. Study subjects can always withdraw from the 
study at any time and this will be made clear to them. We will specifically exclude 
individuals who are taking sildenafil (Viagra®), tadalafil (Cialis®), or vardenafil (Levitra®) 
and we will instruct them not to take these medications while participating in the study, as 
well as the risks associated with this combination. If subjects express the wish to take 
these medications within the 24 weeks following consent, they will not be included in the 
study. We will exclude subjects with a history of kidney stones, since vitamin C may 
precipitate the recurrence of oxalate kidney stones. We will also exclude patients with 
G6PD deficiency,  since vitamin C may precipitate hemolysis in this condition.72, 73 
e. Measures to minimize the risk of breach in confidentiality: All records will be 
treated with strict confidentiality according to HIPAA guidelines (all study personnel are 
trained on HIPAA regulations). Blood samples obtained from subjects will be used only 
for research purposes. Records will be treated with strict confidentiality and stored in a 
secured, limited access area. A subject ID number rather than name will identify all 
collected samples and images. A secure database of patient information will be 
maintained. Only the investigators will have access to research information and will follow 
IRB and institutional HIPAA guidelines. Paper files will be saved under lock in a secure 
IRB-approved area. 
 
f. Other measures to minimize risk: Phlebotomy, arterial tonometry and Doppler 
echocardiographic examinations will only be performed by appropriately trained personnel 
as per our institutional standards. These procedures will be performs in CTRC-based 
cardiovascular phenotyping unit at either HUP or Penn Presbyterian medical center.  
F.3. POTENTIAL BENEFITS OF THE PROPOSED RESEARCH TO THE SUBJECTS 
AND OTHERS 
There are no anticipated direct benefits to the subjects as a result of their participation in 
this study nor will this be implied when obtaining consent. However, if our hypothesis is 
correct, subjects in the active medication groups may experience improvements in their f 
LV hypertrophy and fibrosis, which are associated with the risk of heart failure. However, 
any potential benefit will not be implied during informed consent or enrollment. The results 
of this study may ultimately lead to an effective strategy to prevent HF in CKD, which is 
urgently needed. Since there is minimal risk and potential benefits to medical knowledge 
and society, the risk / benefit ratio is acceptable.  
 
Overall, the minimal risk to human subjects for participation in this study is greatly 


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outweighed by potential scientific knowledge that may result from this work. 
 
F. 4. IMPORTANCE OF THE KNOWLEDGE GAINED 
If our hypothesis of a causal role is correct, this study may identify a potential intervention 
to induce reserve remodeling and prevent incident heart failure in CKD patients. 
Furthermore, if targeting wave reflections improves diastolic function, LV remodeling and 
the clinical status of CKD patients, this would lead to a better understanding of the 
mechanisms that lead to, or contribute to, cardiac dysfunction in CKD, which will 
accelerate the discovery of new treatments for this condition. 
G. DATA AND SAFETY MONITORING PLAN 
1. Adverse events 
The Principal Investigator will be responsible for ensuring that all adverse events are 
noted, followed and reported to the IRB and DSMB as appropriate. The PI will continuously 
supervise all aspects of the study and review the records of the study subjects following 
each visit and at the end of their participation. Any adverse events (AE) will be rated on a 
0-5 scale (S0-no AE; 1-mild AE, no treatment required; 2-moderate AE that responds to 
treatment; 3-severe AE that would limit normal activities and require a prolongation of 
hospitalization; 4-life-threatening or disabling AE; 5-Fatal AE). Any AE rated >=3 will be 
immediately reported to the IRB. All AEs will be reported to the IRB on an annual basis. 
In the case of a serious AE, the IRB will makes a determination about the necessity to 
modify the protocol, include additional information in the consent form, inform previous 
participants, temporarily hold enrollment of patients, or terminate the study. All study 
procedures and cumulative adverse events are subject to full committee review at least 
yearly.  
Adverse events known to be associated with ISMN include: 
• 
Headache 
• 
Mild dizziness 
• 
Warmth, redness, or tingly feeling under skin 
• 
Pounding heart beat 
• 
Dry mouth 
• 
Nausea/Vomiting 
• 
Sweating 
• 
Feelings of passing out 
• 
An allergic reaction to this drug is very rare, but could manifest as hives, difficulty 
breathing, or swelling of the face, lips, tongue, or throat. 
• Symptomatic hypotension. 
 
 


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Adverse effects that may be associated with vitamin C include:54, 55 
• Diarrhea 
• Nausea 
• Vomiting 
• Heartburn 
• Stomach cramps 
• Headache 
 
These will be specifically monitored during the study visits and calls. Any additional 
adverse events will be assessed by the PI (Dr. Chirinos, cardiologist) in consultation with 
Dr. Townsend (nephrologist and hypertension expert) to determine the relatedness to the 
study drug, the best clinical action to ensure patient safety, and the appropriate 
classification of the events for reporting purposes.  
 
2. Data and Safety Monitoring Board (DSMB) 
We will establish a Data Safety Monitoring Board to oversee the study. The initial DSMB 
meeting will be held as soon as possible after a notice of grant award and before initiating 
enrollment. Thereafter, the DSMB will meet via teleconference (when 40% of patients 
have been enrolled; when 80% of patients have been enrolled, and when all patients have 
closed out of the study). The meetings will consist of an open format meeting, since there 
is no blinding in the R56 phase of the study. All SAE’s will be reported to the DSMB in a 
timely manner as per NIH guidelines.  
 
DSMB meetings will generally be conducted by teleconference and coordinated by the 
Research Staff Team at the University of Pennsylvania.  
 
A quorum, defined as the chairperson and the DSMB statistician will be required to hold a 
DSMB meeting. Critical decisions of the DSMB should be made by unanimous vote. 
However, if this is not possible, majority vote will decide. In addition to the PI, a facilitator 
(a member of the research staff) will attend the DSMB meetings as a non-voting member 
in order to facilitate data presentation and follow-up reporting, unless deemed not 
necessary by the DSMB.  
 
Our DMSB will have 3 members, including an expert in hypertension, a nephrologist and 
one biostatistician. As per NIH guidelines for locally appointed boards, our local IRB will 
be responsible for ensuring adequate / appropriate membership. We will follow our 
institutions’ conflict of interest policy. No member of the DSMB will have direct involvement 
in the conduct of the study. Furthermore, no member will have financial, proprietary, 
professional, or other interests that may affect impartial, independent decision-making by 
the DSMB. All DSMB and ad hoc members will sign a Conflict of Interest certification to 
that effect at the time they are asked to participate. Interests that may create a potential 
conflict of interest should be disclosed to the DSMB prior to any further discussion. The 


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DSMB will determine how to handle such potential conflict. The DSMB can require that a 
member with a potential conflict not vote or take other means deemed appropriate. Our 
proposed DSMB member list is attached to this document.  
The primary responsibilities of the DSMB will be to 1) periodically review and evaluate the 
accumulated study data for participant safety, study conduct and progress, and 2) make 
determinations concerning the continuation, modification, or termination of the study. The 
DSMB will review the study protocol for prior to implementation of the study and may 
request changes to adverse event monitoring procedures. 
Initial meeting: The initial DSMB meeting is planned for October 2015. At this meeting the 
DSMB should discuss the protocol and the DSMB charter, which includes triggers set for 
data review or analyses, definition of a quorum, and guidelines for monitoring the study. 
Guidelines will also address stopping the study for safety concerns. At this meeting, the 
DSMB will also develop procedures for conducting business (e.g., voting rules, 
attendance, etc.).  
Recurring reports and meetings: The DSMB will convene via conference call at 
predetermined milestones (when 40% of patients have been enrolled; when 80% of 
patients have been enrolled; when all patients have closed out of the study) and review 
the incidence of adverse events. The DSMB will have the power to recommend 
termination of the study based on the evaluation of these results, due to safety concerns. 
The Principal Investigator, along with the study biostatistician, will complete reports, 
detailing the study progress status, cumulative data for adverse events any protocol 
deviations. All data in the open report, including adverse event data, will not be grouped 
by treatment period, to preserve blinding to the investigators. No interim efficacy analyses 
are planned unless requested by the DSMB. Any factors external to the study such as 
scientific or therapeutic developments that may impact participant safety or the ethics of 
the study will also be discussed. Confidentiality will always be maintained during all 
phases of DSMB review and deliberations.  
The DSMB will conclude each review with their recommendations to the NIH program 
officer as to whether the study should continue without change, be modified, or terminated. 
After each meeting, monitoring board meeting minutes will summarize the topics 
discussed and list the all recommendations. After each board meeting, throughout the 
active phase of a study, the lead investigators will arrange for a summary of board 
recommendations to be sent to each participating IRB. 
 
A final report after each meeting will be prepared and submitted to the NIH Program Officer 
and the Awardee’s Institution IRB. This report will include all adverse events. 


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Expedited reporting will occur for all deaths as per the following guidelines 
(http://www.nia.nih.gov/research/dea/implementation-policies-human-intervention-
studies), usually within 24 hours of study’s knowledge of death. The report of death will be 
submitted to NIA Program Officer and to the DSMB Chair. When SAEs occur that are 
unanticipated (i.e., not listed in the Data and Safety Monitoring Plan) and that are related 
to the intervention, they will be reported to NIH Program Officer and to the DSMB Chair, 
within 48 hours of study’s knowledge of SAE.  
A summary of all other SAEs will be reported to NIH Program Officer and to the DSMB 
during each report.  
APPENDIX I      
ISMN prescribing information 
 
 
IMDUR® 
(isosorbide mononitrate) 
Extended Release Tablets 
 
DESCRIPTION 
Isosorbide mononitrate (ISMN), an organic nitrate and the major biologically active 
metabolite of isosorbide dinitrate (ISDN), is a vasodilator with effects on both 
arteries and veins. 
IMDUR® Tablets, for oral administration, contain either 30 mg, 60mg or 120 mg of 
isosorbide mononitrate in an extended-release formulation. In addition, each tablet 
contains the following inactive ingredients: col loidal silicon dioxide,  hydrogenated 
castor 
oil, 
hypromellose, 
lactose 
monohydrate, 
magnesium 
stearate, 
microcrystalline cellulose and talc. 
The molecular formula of ISMN is C6H9NO6 and the molecular weight 
is 191.14. The chemical name for ISMN is 1,4:3,6-dianhydro-,Dglucitol 
5-nitrate; the compound has the following structural formula: 
 


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ISMN is a white, crystalline, odorless compound which is stable in air and in 
solution, has a melting point of about 90°C, and an optical rotation of +144° (2% in 
water, 20°C). Isosorbide mononitrate is freely soluble in water, ethanol, methanol, 
chloroform, ethyl acetate, and dichloromethane. 
 
CLINICAL PHARMACOLOGY 
 
Mechanism of Action 
The IMDUR product is an oral extended-release formulation of ISMN, the major 
active metabolite of isosorbide dinitrate; most of the clinical activity of the dinitrate 
is attributable to the mononitrate. The principal pharmacological action of ISMN 
and all organic nitrates in general is relaxation of vascular smooth muscle, 
producing dilatation of peripheral arteries and veins, especially the latter. Dilatation 
of the veins promotes peripheral pooling of blood, decreases venous return to the 
heart, thereby reducing left ventricular end-diastolic pressure and pulmonary 
capillary wedge pressure (preload). Arteriolar relaxation reduces systemic 
vascular resistance, systolic arterial pressure and mean arterial pressure 
(afterload). Dilatation of the coronary arteries also occurs. The relative importance 
of preload reduction, afterload reduction, and coronary dilatation remains 
undefined. 
 
Pharmacodynamics 
Dosing regimens for most chronically used drugs are designed to provide plasma 
concentrations that are continuously greater than a minimally effective 
concentration. This strategy is inappropriate for organic nitrates. Several well-
controlled clinical trials have used exercise testing to assess the antianginal 
efficacy of continuously delivered nitrates. In the large majority of these trials, 
active agents were indistinguishable from placebo after 24 hours (or less) of 
continuous therapy. Attempts to overcome tolerance by dose escalation, even to 
doses far in excess of those used acutely, have consistently failed. Only after 
nitrates have been absent from the body for several hours has their antianginal 
efficacy been restored. IMDUR Tablets, during long-term use over 42 days dosed 
at 120 mg once daily, continued to improve exercise performance at 4 hours and 
at 12 hours after dosing but its effects (although better than placebo) are less than 
or at best equal to the effects of the first dose of 60 mg. 
 
Pharmacokinetics and Metabolism 
After oral administration of ISMN as a solution or immediate-release tablets, 
maximum plasma concentrations of ISMN are achieved in 30 to 60 minutes, with 
an 
absolute 
bioavailability 
of 
approximately 
100%. 
After 
intravenous 
administration, ISMN is distributed into total body water in about 9 minutes with a 


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28
 
 
 
 
 
 
volume of distribution of approximate ly 0.6-0.7 L/kg. Isosorbide mononitrate is 
approximately 5% bound to human plasma proteins and is distributed into blood 
cells and saliva. Isosorbide mononitrate is primarily metabolized by the liver, but 
unlike oral isosorbide dinitrate, it is not subject to first pass metabolism. Isosorbide 
mononitrate is cleared by denitration to isosorbide and glucuronidation as the 
mononitrate, with 96% of the administered dose excreted in the urine within 5 days 
and only about 1% eliminated in the feces. At least six different compounds have 
been detected in urine, with about 2% of the dose excreted as 
the unchanged drug and at least five metabolites. The metabolites are not 
pharmacologically active. Renal clearance accounts for only about 4% of total body 
clearance. The mean plasma elimination half-life of ISMN is approximately 5 hours. 
The disposition of ISMN in patients with various degrees of renal insufficiency, liver 
cirrhosis, or cardiac dysfunction was evaluated and found to be similar to that 
observed in healthy subjects. The elimination half-life of ISMN was not prolonged, 
and there was no drug accumulation in patients with chronic renal failure after 
multiple oral dosing. The pharmacokinetics and/or bioavailability of IMDUR Tablets 
have been studied in both normal volunteers and patients following single and 
multiple-dose administration. Data from these studies suggest that the 
pharmacokinetics of ISMN administered as IMDUR Tablets are similar between 
normal healthy volunteers and patients with angina pectoris. In single- and 
multiple-dose studies, the pharmacokinetics of ISMN were dose proportional 
between 30 mg and 240 mg. In a multiple-dose study, the effect of age on the 
pharmacokinetic profile of IMDUR 60 mg and 120 mg (2 x 60 mg) was evaluated 
in subjects ≥45 years. The results of that study indicate that there are no significant 
differences in any of the pharmacokinetic variables of ISMN between elder ly (≥65 
years) and younger individuals (45-64 years) for the IMDUR 60 mg dose. The 
administration of IMDUR Tablets 120 mg (2 x 60 mg tablets every 24 hours for 7 
days) produced a dose-proportional increase in Cmax and AUC, without changes 
in Tmax or the terminal half-life. The older group (65-74 years) showed 30% lower 
apparent oral clearance (Cl/F) following the higher dose, i.e., 120 mg, compared 
to the younger group (45-64 years); Cl/F was not different between the two groups 
following the 60 mg regimen. While Cl/F was independent of dose in the younger 
group, the older group showed slightly lower Cl/F following the 120 mg regimen 
compared to the 60 mg regimen. Differences between the two age groups, 
however, were not statistically significant. In the same study, females showed a 
slight (15%) reduction in clearance when the dose was increased. Females 
showed higher AUCs and Cmax compared to males, but these differences were 
accounted for by differences in body weight between the two groups. When the 
data were analyzed using age as a variable, the results indicated that there were 
no significant differences in any of the pharmacokinetic variables of ISMN between 
older (≥65 years) and younger individuals (45-64 years). The results of this study, 


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29
 
 
 
 
 
 
however, should be viewed with caution due to the small number of subjects in 
each age subgroup and consequently the lack of sufficient statistical power. 
The following table summarizes key pharmacokinetic parameters of ISMN after 
single- and multiple-dose administration of ISMN as an oral solution or IMDUR 
Tablets: 
 
 
Food Effects 
The influence of food on the bioavailability of ISMN after single-dose administration 
of IMDUR Tablets 60 mg was evaluated in three different studies involving either 
a “light” breakfast or a high-calorie, high-fat breakfast. Results of these studies 
indicate that concomitant food intake may decrease the rate (increase in Tmax) 
but not the extent (AUC) of absorption of ISMN. 
 
Clinical Trials 
Controlled trials with IMDUR Tablets have demonstrated antianginal activity 
following acute and chronic dosing. Administration of IMDUR Tablets once daily, 
taken early in the morning on arising, provided at least 12 hours of antianginal 
activity. In a placebo-controlled parallel study, 30, 60, 120 and 240 mg of IMDUR 
Tablets were administered once daily for up to 6 weeks. Prior to randomization, all 
patients completed a 1- to 3-week single-blind placebo phase to demonstrate 
nitrate responsiveness and total exercise treadmill time reproducibility. Exercise 
tolerance tests using the Bruce Protocol were conducted prior to and at 4 and 12 
hours after the morning dose on days 1, 7, 14, 28 and 42 of the doubleblind period. 
IMDUR Tablets 30 and 60 mg (only doses evaluated acutely) demonstrated a 
significant increase from baseline in total treadmill time relative to placebo at 4 and 
12 hours after the administration of the first dose. At day 42, the 120 and 240 mg 


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dose of IMDUR Tablets demonstrated a significant increase in total treadmill time 
at 4 and 12 hours post dosing, but by day 42, the 30 and 60 mg doses no longer 
were differentiable from placebo. Throughout chronic dosing, rebound was not 
observed in any IMDUR treatment group. Pooled data from two other trials, 
comparing IMDUR Tablets 60 mg once daily, ISDN 30 mg QID, and placebo QID 
in patients with chronic stable angina using a randomized, double-blind, three-way 
crossover design found statistically significant increases in exercise tolerance 
times for IMDUR Tablets compared to placebo at hours 4, 
8 and 12 and to ISDN at hour 4. The increases in exercise tolerance on day 14, 
although statistically significant compared to placebo, were about half of that seen 
on day 1 of the trial.  
 
INDICATIONS AND USAGE 
IMDUR Tablets are indicated for the prevention of angina pectoris due to coronary 
artery disease. The onset of action of oral isosorbide mononitrate is not sufficiently 
rapid for this product to be useful in aborting an acute anginal episode. 
 
CONTRAINDICATIONS 
IMDUR Tablets are contraindicated in patients who have shown hyper sensitivity 
or idiosyncratic reactions to other nitrates or nitrites. 
 
WARNINGS 
Amplification of the vasodilatory effects of IMDUR by sildenafil can result in 
severe hypotension. The time course and dose dependence of this 
interaction have not been studied. Appropriate supportive care has not been 
studied, but it seems reasonable to treat this as a nitrate overdose, with 
elevation of the extremities and with central volume expansion. The benefits 
of ISMN in patients with acute myocardial infarction or congestive heart failure 
have not been established; because the effects of isosorbide mononitrate are 
difficult to terminate rapidly, this drug is not recommended in these settings. 
If isosorbide mononitrate is used in these conditions, careful clinical or 
hemodynamic monitoring must be used to avoid the hazards of hypotension and 
tachycardia. 
 
PRECAUTIONS 
General 
Severe hypotension, particularly with upright posture, may occur with even small 
doses of isosorbide mononitrate. This drug should, therefore, be used with caution 
in patients who may be volume depleted or who, for whatever reason, are already 
hypotensive. 
Hypotension induced by isosorbide mononitrate may be accompanied by 
paradoxical bradycardia and increased angina pectoris. Nitrate therapy may 


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31
 
 
 
 
 
 
aggravate the angina caused by hypertrophic cardiomyopathy. In industrial 
workers who have had long-term exposure to unknown (presumably high) doses 
of organic nitrates, tolerance clearly occurs. Chest pain, acute myocardial 
infarction, and even sudden death have occurred during temporary withdrawal of 
nitrates from these workers, demonstrating the existence of true physical 
dependence. The importance of these observations to the routine, clinical use of 
oral isosorbide mononitrate is not known.  
 
Information for Patients 
Patients should be told that the antianginal efficacy of IMDUR Tablets can be 
maintained by carefully following the prescribed schedule of dosing. For most 
patients, this can be accomplished by taking the dose on arising. As with other 
nitrates, daily headaches sometimes accompany treatment with isosorbide 
mononitrate. In patients who get these headaches, the headaches are a marker of 
the activity of the drug. 
Patients should resist the temptation to avoid headaches by altering the schedule 
of their treatment with isosorbide mononitrate, since loss of headache may be 
associated with simultaneous loss of antianginal efficacy. Aspirin or 
acetaminophen often successfully relieves isosorbide mononitrate-induced 
headaches with no deleterious effect on isosorbide mononitrate’s antianginal 
efficacy.  
Treatment with isosorbide mononitrate may be associated with lightheadedness 
on standing, especially just after rising from a recumbent or seated position. This 
effect may be more frequent in patients who have also consumed alcohol. 
 
Drug Interactions 
The vasodilating effects of isosorbide mononitrate may be additive with those of 
other vasodilators. Alcohol, in particular, has been found to exhibit additive effects 
of this variety. Marked symptomatic orthostatic hypotension has been reported 
when calcium channel blockers and organic nitrates were used in combination. 
Dose adjustments of either class of agents may be necessary. 
 
Drug/Laboratory Test Interactions 
Nitrates and nitrites may interfere with the Zlatkis-Zak color reaction, causing 
falsely low readings in serum cholesterol determinations.  
 
Carcinogenesis, Mutagenesis, Impairment of Fertility 
No evidence of carcinogenicity was observed in rats exposed to isosorbide 
mononitrate in their diets at doses of up to 900 mg/kg/day for the first 6 months 
and 500 mg/kg/day for the remaining duration of a study in which males were 
dosed for up to 121 weeks and females were dosed for up to 137 weeks. No 


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32
 
 
 
 
 
 
evidence of carcino genicity was observed in mice exposed to isosorbide 
mononitrate in their diets for up to 104 weeks at doses of up to 900 mg/kg/day. 
Isosorbide mononitrate did not produce gene mutations (Ames test, mouse 
lymphoma test) or chromosome aberrations (human lymphocyte and mouse 
micronucleus tests) at biologically relevant concentrations. No effects on fertility 
were observed in a study in which male and female rats were administered doses 
of up to 750 mg/kg/day beginning, in males, 9 weeks prior to mating, and in 
females, 2 weeks prior to mating. 
 
Pregnancy 
 
Teratogenic Effects 
Pregnancy Category B. In studies designed to detect effects of isosorbide 
mononitrate on embryo-fetal development, doses of up to 240 or 248 mg/kg/day, 
administered to pregnant rats and rabbits, were unassociated with evidence of 
such effects. These animal doses are about 100 times the maximum 
recommended human dose (120 mg in a 50 kg woman) when comparison is based 
on body weight; when comparison is based on body surface area, the rat dose is 
about 17 times the human dose and the rabbit dose is about 38 times the human 
dose. There are, however, no adequate and well-controlled studies in 
pregnant women. Because animal reproduction studies are not always predictive 
of human response, IMDUR Tablets should be used during pregnancy only if 
clearly needed. 
 
Nonteratogenic Effects 
Neonatal survival and development and incidence of stillbirths were adversely 
affected when pregnant rats were administered oral doses of 750 (but not 300) mg 
isosorbide mononitrate/kg/day during late gestation and lactation. This dose (about 
312 times the human dose when comparison is based on body weight and 54 times 
the human dose when comparison is based on body surface area) was associated 
with decreases in maternal weight gain and motor activity and evidence of impaired 
lactation. 
 
Nursing Mothers 
It is not known whether this drug is excreted in human milk. Because many drugs 
are excreted in human milk, caution should be exercised when ISMN is 
administered to a nursing mother.  
 
Pediatric Use 
The safety and effectiveness of ISMN in pediatric patients have not been 
established. 
 


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Geriatric Use 
Clinical studies of IMDUR Tablets did not include sufficient information on patients 
age 65 and over to determine whether they respond differently from younger 
patients. Other reported clinical experience for IMDUR has not identified 
differences in response between elderly and younger patients. Clinical experience 
for organic nitrates reported in the literature identified a potential for severe 
hypotension and increased sensitivity to nitrates in the elderly. In general, dose 
selection for an elderly patient should be cautious, usually starting at the low end 
of the dosing range, reflecting the greater frequency of decreased hepatic, renal, 
or cardiac function, and of concomitant disease or other drug therapy. Elderly 
patients may have reduced baroreceptor function and may develop severe 
orthostatic hypotension when vasodilators are used. IMDUR should therefore be 
used with caution in elderly patients who may be volume depleted, on multiple 
medications or who, for whatever reason, are already hypotensive. Hypotension 
induced by isosorbide mononitrate may be accompanied by paradoxical 
bradycardia and increased angina pectoris. 
Elderly patients may be more susceptible to hypotension and may be at a greater 
risk of falling at therapeutic doses of nitroglycerin. Nitrate therapy may aggravate 
the angina caused by hypertrophic car diomyopathy, particularly in the elderly. 
 
ADVERSE REACTIONS 
The table below shows the frequencies of the adverse events that occurred in >5% 
of the subjects in three placebo-controlled North American studies in which 
patients in the active treatment arm received 30 mg, 60 mg, 120 mg, or 240 mg of 
isosorbide mononitrate as IMDUR Tablets once daily. In parentheses, the same 
table shows the frequencies with which these adverse events were associated with 
the discontinuation of treatment. Overall, 8% of the patients who received 30 mg, 
60 mg, 120 mg, or 240 mg of isosorbide mononitrate in the three placebo-
controlled North American studies discontinued treatment because of adverse 
events.  
Most of these discontinued because of headache. Dizziness was rarely associated 
with withdrawal from these studies. Since headache appears to be a dose-related 
adverse effect and tends to disappear with continued treatment, it is recommended 
that IMDUR treatment be initiated at low doses for several days before being 
increased to desired levels. 
 
FREQUENCY AND ADVERSE EVENTS (DISCONTINUED)* 


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34
 
 
 
 
 
 
 
*Some individuals discontinued for multiple reasons. 
**Patients were started on 60 mg and titrated to their final dose. 
 
In addition, the three North American trials were pooled with 11 controlled trials 
conducted in Europe. Among the 14 controlled trials, a total of 711 patients were 
randomized to IMDUR Tablets. When the pooled data were reviewed, headache 
and dizziness were the only adverse events that were reported by >5% of patients. 
Other adverse events, each reported by ≤5% of exposed patients, and in many 
cases of uncertain relation to drug treatment, were: 
Autonomic Nervous System Disorders: Dry mouth, hot flushes. 
Body as a Whole: Asthenia, back pain, chest pain, edema, fatigue, fever, flu-like 
symptoms, malaise, rigors. Cardiovascular Disorders, General: Cardiac failure, 
hypertension, hypotension. Central and Peripheral Nervous System Disorders: 
Dizziness, headache, hypoesthesia, migraine, neuritis, paresis, paresthesia, 
ptosis, tremor, vertigo. Gastrointestinal System Disorders: Abdominal pain, 
constipation, diarrhea, dyspepsia, flatulence, gastric ulcer, gastritis, glossitis,  
hemorrhagic gastric ulcer, hemorrhoids, loose stools, melena, nausea, vomiting. 
Hearing and Vestibular Disorders: Earache, tinnitus, tympanic membrane 
perforation. Heart Rate and Rhythm Disorders: Arrhythmia, arrhythmia atrial, 
atrial fibrillation, bradycardia, bundle branch block, extrasystole, palpitation, 
tachycardia, ventricular tachycardia. Liver and Biliary System Disorders: SGOT 
increase, SGPT increase. Metabolic and Nutritional Disorders: Hyperuricemia, 
hypokalemia. Musculoskeletal System Disorders: Arthralgia, frozen shoulder, 
muscle weakness, musculoskeletal pain, myalgia, myositis, tendon disorder, 
torticollis. Myo-, Endo-, Pericardial and Valve Disorders: Angina pectoris 
aggravated, heart murmur, heart sound abnormal, myocardial infarction, Q wave 
abnormality. 
Platelet, 
Bleeding 
and 
Clotting 
Disorders: 
Purpura, 
thrombocytopenia. Psychiatric Disorders: Anxiety, concentration impaired, 
confusion, decreased libido, depression, impotence, insomnia, nervousness, 
paroniria, somnolence. Red Blood Cell Disorder: Hypochromic anemia. 
Reproductive Disorders, Female: Atrophic vaginitis, breast pain. 
Resistance Mechanism Disorders: Bacterial infection, moniliasis, viral infection. 


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Respiratory System Disorders: Bronchitis, bronchospasm, coughing, dyspnea, 
increased sputum, nasal congestion, pharyngitis, pneumonia, pulmonary 
infiltration, rales, rhinitis, sinusitis. Skin and Appendages Disorders: Acne, hair 
texture abnormal, increased sweating, pruritus, rash, skin nodule. Urinary System 
Disorders: Polyuria, renal calculus, urinary tract infection. Vascular (Extracardiac) 
Disorders: Flushing, intermittent claudication, leg ulcer, varicose vein. Vision 
Disorders: Conjunctivitis, photophobia, vision abnormal. In addition, the following 
spontaneous adverse event has been reported during the marketing of isosorbide 
mononitrate: syncope.  
 
OVERDOSAGE 
 
Hemodynamic Effects 
The ill effects of isosorbide mononitrate overdose are generally the result of 
isosorbide mononitrate’s capacity to induce vasodilatation, venous pooling, 
reduced cardiac output, and hypotension. These hemodynamic changes may have 
protean manifestations, including increased intracranial pressure, with any or all of 
persistent throbbing headache, confusion, and moderate fever; vertigo, 
palpitations; visual disturbances; nausea and vomiting (possibly with colic and 
even bloody diarrhea); syncope (especially in the upright posture); air hunger and 
dyspnea, later followed by reduced ventilatory effort; diaphoresis, with the skin 
either flushed or cold and clammy; heart block and bradycar dia; paralysis; coma; 
seizures and death. 
Laboratory determinations of serum levels of isosorbide mononitrate and its 
metabolites are not widely available, and such determinations have, in any event, 
no established role in the management of isosorbide mononitrate overdose. There 
are no data suggesting what dose of isosorbide mononitrate is likely to be life 
threatening in humans. In rats and mice, there is significant lethality at doses of 
2000 mg/kg and 3000 mg/kg, respectively. 
No data are available to suggest physiological maneuvers (eg, maneuvers to 
change the pH of the urine) that might accelerate elimination of isosorbide 
mononitrate. In particular, dialysis is known to be ineffective in removing isosorbide 
mononitrate from the body. No specific antagonist to the vasodilator effects of 
isosorbide mononitrate is known, and no intervention has been subject to 
controlled study as a therapy of isosorbide mononitrate overdose. Because the 
hypotension associated with isosorbide mononitrate overdose is the result of 
venodilatation and arterial hypovolemia, prudent therapy in this situation should be 
directed toward an increase in central fluid volume. Passive elevation of the 
patient’s legs may be sufficient, but intravenous infusion of normal saline or similar 
fluid may also be necessary. The use of epinephrine or other arterial 
vasoconstrictors in this setting is likely to do more harm than good. In patients with 
renal disease or congestive heart failure, therapy resulting in central volume 


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36
 
 
 
 
 
 
expansion is not without hazard. Treatment of isosorbide mononitrate overdose in 
these patients may be subtle and difficult, and invasive monitoring may be 
required. 
 
Methemoglobinemia 
Methemoglobinemia has been reported in patients receiving other organic nitrates, 
and it probably could also occur as a side effect of isosorbide mononitrate. 
Certainly nitrate ions liberated during metabolism of isosorbide mononitrate can 
oxidize hemoglobin into methemo globin. Even in patients totally without 
cytochrome b5 reductase activity, however, and even assuming that the nitrate 
moiety of isosorbide mononitrate is quantitatively applied to oxidation of 
hemoglobin, about 2 mg/kg of isosorbide mononitrate should be required before 
any of these patients manifest clinically significant (≥10%) methemoglobine mia. 
In 
patients 
with 
normal 
reductase 
function, 
significant 
production 
of 
methemoglobin should require even larger doses of isosorbide mononitrate. In one 
study in which 36 patients received 2-4 weeks of continuous nitroglycerin therapy 
at 3.1 to 4.4 mg/hr (equivalent, in total administered dose of nitrate ions, to 7.8-
11.1 mg of isosorbide mono-nitrate per hour), the average methemoglobin level 
measured was 0.2%; this was comparable to that observed in parallel patients who 
received placebo. Notwithstanding these observations, there are case reports of 
significant methemoglobinemia in association with moderate overdoses of organic 
nitrates. None of the affected patients had been thought to be unusually 
susceptible. 
Methemoglobin levels are available from most clinical laboratories. The diagnosis 
should be suspected in patients who exhibit signs of impaired oxygen delivery 
despite adequate cardiac output and adequate arterial pO2. Classically, 
methemoglobinemic blood is described as chocolate brown without color change 
on exposure to air. When methemoglobinemia is diag nosed, the treatment of 
choice is methylene blue, 1-2 mg/kg intravenously. 
 
DOSAGE AND ADMINISTRATION 
The recommended starting dose of IMDUR Tablets is 30 mg (given as a single 30 
mg tablet or as 1/2 of a 60 mg tablet) or 60 mg (given as a single tablet) once daily. 
After several days, the dosage may be increased to 120 mg (given as a single 120 
mg tablet or as two 60 mg tablets) once daily. Rarely, 240 mg may be required. 
The daily dose of IMDUR Tablets should be taken in the morning on arising. 
IMDUR Extended Release Tablets should not be chewed or crushed and should 
be swallowed together with a half-glassful of fluid. Do not break the 30 mg tablet.  
 
HOW SUPPLIED 


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IMDUR Extended Release Tablets 30 mg are white, capsule-shaped tablets 
scored on one side and engraved “IMDUR” on the unscored side. They are 
supplied as follows:  
Bottles of 100 NDC 0085-1374-01 
IMDUR Extended Release Tablets 60 mg are white, capsule-shaped tablets 
scored on one side with “60-60” and engraved “IMDUR” on the unscored side. 
They are supplied as follows:  
Bottles of 100 NDC 0085-2028-01 
IMDUR Extended Release Tablets 120 mg are white, capsule-shaped tablets 
engraved “IMDUR” on one side and “120” on the other side. 
They are supplied as follows: 
Bottles of 100 NDC 0085-0091-01 
Store at controlled room temperature 20°-30°C (68°-86°F) [See USP]. 
IMDUR® 
(isosorbide mononitrate) 
Extended Release Tablets 
Manufactured by: Kremers Urban Pharmaceuticals Inc., 
Seymour, IN 47274, USA 
Distributed by: Schering Corporation, a subsidiary of Whitehouse Station, NJ 
08889, USA 
 
 
 
 


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APPENDIX II 
 
List of procedures / visits and schedule of events 
 
A. List of procedures per visit 
 
Baseline Visit 
• Read and sign this informed consent form (ICF). 
• If you are a pre-menopausal woman, confirm that you 
are not pregnant by a urine pregnancy test. 
• Have a medical history assessment, a physical, and 
record vital signs.  
• Have your blood drawn and collect urine. 
• Arterial Tonometry / VaSera test. 
• Have a Doppler Echocardiogram. 
• Complete the MRI of your Heart. 
• Setup the 24 Hour BP monitoring and pulse wave 
analysis watch. 
• Medication given out. 
• Bicycle Exercise Test 
• Activity Monitor 
Week 1 Visit  
• Collect Vital Signs. 
• Review Side Effects 
• Increase medication dose to 60 mg daily.  
• Collect medication of the previous dose.  
• Arterial Tonometry / VaSera test. 
• Download and replacement of pulse wave analysis watch 
• Blood draw and urine collection 
• 24 Hour BP Monitoring 
• Activity Monitor 
Week 2 Visit  
• Collect Vital Signs. 
• Review Side Effects 
• Increase medication dose to 120 mg daily.  
• Collect medication of the previous dose.  
• Download and replacement of pulse wave analysis watch 
• Collect information on potential side effects. 
• Arterial Tonometry / VaSera test. 
• Replace pulse wave analysis watch. 


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• Medication given out.  
• Arterial Tonometry and VaSera 
• 24 Hour BP Monitoring 
• Activity Monitor 
Week 3 Visit  
• Collect Vital Signs. 
• Review Side Effects 
• 24 Hour BP Monitoring and pulse wave analysis 
watch Arterial Tonometry / VaSera test. 
• Have a Doppler Echocardiogram.  
• Bicycle Exercise Test 
• Blood Draw and urine collection 
• Activity Monitor: 2 weeks prior visit 
3 Month Visit 
• The Arterial Tonometry and VaSera test. 
• Have a Doppler Echocardiogram. 
• Setup the 24 Hour BP monitoring and pulse wave 
analysis watch. 
• Medication given out. 
• Activity Monitor: 2 weeks prior to the visit 
• Review Side Effects 
• Blood Draw and urine collection 
6 Month Visit 
• If you are a pre-menopausal woman, confirm that you 
are not pregnant by a urine pregnancy test 
• Have a medical history assessment, a physical, and 
record vital signs.  
• Review Side Effects 
• Have your blood drawn and urine collection. 
• The Arterial Tonometry and VaSera test. 
• Have a Doppler Echocardiogram. 
• Complete the MRI of your Heart. 
• Setup the 24 Hour BP monitoring and pulse wave 
analysis watch. 
• After 2 days of wearing pulse wave analysis watch, 
discontinue the medication. 
• Bicycle Exercise Test 
• Activity Monitor: 2 weeks prior to the visit 
 


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B. Schedule of events 
Test 
Baseline 
visit 
Week 
1 
Week 
2 
Week 
3 
Week 
12 
Week 
24 
Medical History 
X 
 
 
 
 
X 
Physical  
X 
 
 
 
 
X 
Vital Signs 
X 
X 
X 
X 
X 
X 
Potential change in study medication 
 
X 
X 
X 
 
 
ArterialTonometry and VaSera 
X 
X 
X 
X 
X 
X 
Doppler Echocardiogram  
 
X 
 
 
X 
X 
X 
• 24 Hour BP Monitoring  
 
X 
 
 
X 
X 
X 
• Pulse wave analysis watch  
 
X 
X 
X 
X 
X 
X 
• Cardiac MRI 
 
X 
 
 
 
 
X 
• Blood 
draw 
and 
urine 
collection 
 
X 
X 
X 
X 
X 
X 
Review Side Effects 
 
X 
X 
X 
X 
X 
Activity Monitor 
X 
X 
X 
X 
2 
weeks 
prior to 
the visit 
2 
weeks 
prior to 
the visit 
Bicycle Exercise Test 
X 
 
 
X 
 
x 
 
References 
 
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Dhingra R, Gaziano JM and Djousse L. Chronic kidney disease and the risk of heart 
failure in men. Circ Heart Fail. 2011;4:138-44. 
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Bibbins-Domingo K, Chertow GM, Fried LF, Odden MC, Newman AB, 
Kritchevsky SB, Harris TB, Satterfield S, Cummings SR and Shlipak MG. Renal function 
and heart failure risk in older black and white individuals: the Health, Aging, and Body 
Composition Study. Arch Intern Med. 2006;166:1396-402. 
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Chirinos JA, Khan A, Bansal N, Dries DL, Feldman HI, Ford V, Anderson AH, 
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AS, Townsend RR, Investigators CS and Investigators CS. Arterial stiffness, central 
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Centers for Disease Control and Prevention. National Chronic Kidney Disease Fact 
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Aus dem Siepen F, Buss SJ, Messroghli D, Andre F, Lossnitzer D, Seitz S, Keller 
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Stuckey DJ, McSweeney SJ, Thin MZ, Habib J, Price AN, Fiedler LR, Gsell W, 
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Kramer CM, Chandrashekhar Y and Narula J. T1 mapping by CMR in 
cardiomyopathy: a noninvasive myocardial biopsy? JACC Cardiovasc Imaging. 
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Miller CA, Naish JH, Bishop P, Coutts G, Clark D, Zhao S, Ray SG, Yonan N, 
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