Conditions: Human Immunodeficiency Virus Coronary Artery Disease
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 19
Healthy volunteers: no

Brief summary:
The investigators propose a pilot study using (1) MRI to assess coronary artery endothelial function, (2) brachial ultrasound to assess systemic endothelial function, (3) serum markers of inflammation and of endothelial cell function and (4) echocardiographic measures of left ventricular diastolic and systolic properties, before and following initiation of PCSK9 antibody in HIV positive subjects.

Detailed description:
To evaluate the effect of the PCSK9 inhibitor evolocumab on coronary and systemic endothelial function, systemic biomarkers of endothelial function and of inflammation, and echocardiographic measures of left ventricular diastolic and systolic properties in subjects who are HIV+. Potential participants will be asked to undergo a screening MRI exam. Those who have evidence of coronary endothelial dysfunction on the MRI exam will receive evolocumab 420 mg sq (the dose that is approved for treatment of hypercholesterolemia) following the screening exam and again at one month. Repeat MRI and ultrasound measures of coronary and systemic endothelial function, as well as serum markers of endothelial function and inflammation, and echocardiographic measures of diastolic and systolic left ventricular function will be obtained at one and six weeks following the first administration of evolocumab.

The investigators will test the hypotheses that PCSK9 inhibition improves endothelial function measured non-invasively on MRI and systemic markers of inflammation at one week (+/- 3 days) and six weeks after initiation of the PCSK9 antibody.

Arms:
arm 1: All enrolled patients will receive evolocumab sq once a month for a total of two doses

Interventions: intervention 1: Evolocumab
Intervention descriptions: intervention 1: Evolocumab sq once a month for a total of two doses

Protocol document:
Prot_SAP_000.pdf: 
 
 
 
 
 
 
 
 
Effect of Evolocumab on 
Coronary Endothelial 
Function 
 
 
 
 
 
 
 
NCT03500302 
 
 
 
 
 
 
 
August 25, 2017 
 
 
 
 
 


Effect of Evolocumab on Coronary Endothelial Function NCT03500302 
  
1.  
Objectives (include all primary and secondary objectives)  
  
To evaluate the effect of the PCSK9 inhibitor evolocumab on coronary 
endothelial function, systemic biomarkers of inflammation, and LDL cholesterol in people 
living with HIV (PLWH). Potential participants will be asked to undergo a screening MRI 
exam.  Those who have evidence of coronary endothelial dysfunction on the MRI exam 
will receive evolocomab 420 mg sq (the dose that is approved for treatment of 
hypercholesterolemia) following the screening exam and again at one month. The 
evolocumab will be administered by the Johns Hopkins Investigational Drug Service in 
the HIV+ group.  Repeat MRI measures of coronary endothelial function, and serum 
markers of endothelial function and inflammation will be obtained at one and six weeks 
following the first administration of evolocumab.    
  
We will test the hypotheses that PCSK9 inhibition improves endothelial function 
measured non-invasively on MRI and systemic markers of inflammation at one week  
and six  weeks after initiation of the PCSK9 antibody in PLWH.   
  
Primary Endpoint:   
  
Coronary endothelial function at 1 week and 6 weeks following initiation of PCSK9 
inhibitor administration; specifically, change in coronary artery cross sectional area 
(CSA) from that at rest to that during isometric handgrip exercise (IHE) stress (as mm2 
and as % rest) at 1 week and 6 weeks. We will be evaluating the change in endothelial 
function from baseline to one week and from baseline to six weeks.  
  
Secondary Endpoints:   
  
1. Change in coronary blood flow (CBF) from rest to that during IHE stress (% rest 
and as ml/min) from baseline to one week and from baseline to six weeks.  
2. Change in inflammatory markers (e.g. hsCRP, IL-6, soluble) and lipids from 
baseline to one week and from baseline to six weeks.  
  
  
Also, the relationship between change in inflammatory markers/lipids over time and 
change in CEF will be quantified and compared.   
  
  
2.  
Background (briefly describe pre-clinical and clinical data, current experience 
with procedures, drug or device, and any other relevant information to justify the 
research)  
  
Increased systemic inflammation and altered lipid metabolism are two factors 
which play important roles in atherogenesis, both in the general population and in HIV+ 
individuals.  Lipid abnormalities are common in HIV infected individuals and may 
contribute to the increased cardiovascular risk in this population. HIV infection itself and 
its treatment with antiretroviral therapy can alter lipid metabolism and both are associated 
with higher LDL cholesterol and triglyceride levels.  In addition, HIV infection is marked 
by increased systemic inflammation, which correlates with the presence and extent of 


Effect of Evolocumab on Coronary Endothelial Function NCT03500302 
  
atherosclerosis, and although systemic inflammatory markers are reduced by ART, they 
are not reduced to normal levels15-18.  Although statins have antiinflammatory properties 
and lower CV mortality in the general population, their use is often problematic in the HIV 
population due to frequent drug interactions and concurrent liver disease.  Importantly, 
CV event rates remain high in HIV+ patients on statin therapy19, 20 and statins alone often 
do not adequately suppress inflammation in many patients20, 21. Therefore, new therapies 
are needed to target the fundamental underlying pathophysiologic mechanisms, namely 
increased inflammation and altered lipid metabolism contributing to HIV-mediated 
atherosclerotic disease. Finally, although traditional imaging methods document the 
anatomic extent of coronary atherosclerosis, there was no prior safe and non-invasive 
way to probe the critical early mechanisms contributing to CAD, namely coronary 
endothelial dysfunction.  However, recent advances by our research group now make it 
possible to non-invasively quantify coronary endothelial function (CEF) and therefore 
better understand the role of inflammation in coronary atherosclerosis.   
  
3. 
Study Procedures  
a. Study design, including the sequence and timing of study procedures    
(distinguish research procedures from those that are part of routine care).  
  
  
The following are research procedures:  
  
HIV positive subjects:  
  
All of the procedures described below are research procedures.  
  
  
Research study of the effect of PCSK9 inhibition in 20 HIV+ subjects (with LDL 
cholesterol > 70 mg/dl) involving (1) subcutaneous administration of two doses of 
evolocumab, (420 mg, one following baseline measures of coronary endothelial function 
and inflammatory mediators and the second one month following the first dose).   For 
this population, we had an FDA exemption for the off label use of evolocumab in this 
study, and the medication will be provided and administered by the Johns Hopkins 
Investigational Drug Service.  HIV+ participants on stable, clinically-guided ART and 
meeting entry criteria will undergo baseline assessment of serum inflammatory 
mediators, as well as PCSK9 activity, lipids, MRI quantification of local coronary 
endothelial function (CEF). Those subjects with abnormal CEF, defined by an increase in 
coronary CSA during IHE of ≤5% from the resting value, will qualify and enter the study. 
Subjects will then receive evolocumab 420 mg sq once after baseline studies and will 
return for repeat clinical assessment, repeat imaging, and blood draw 1 week after 
receiving the dose. Four weeks after receiving the first dose, they will receive a second 
evolocumab dose, with repeat imaging, blood draw, and safety analysis performed at 
week 6 after the first dose (2 weeks after the second administration).  There will be a 
final safety assessment performed at week 10 (6 weeks after final dose given).      
  
Initial evaluation: A careful history and physical examination will be performed. Blood 
samples will be acquired for complete blood cell count, routine chemistry panel including 
hepatic transaminases and creatinine, LDL and HDL cholesterol and triglycerides. 
Serum markers reflective of  inflammation and endothelial function will include serum 
hsCRP, IL-6, TNFα, IFN-γ, and PCSK9 level. Patients will also be tested for hepatitis C 


Effect of Evolocumab on Coronary Endothelial Function NCT03500302 
  
(Hepatitis C Antibody test) if Hep C status is unknown from clinical records. If the patient 
is found to have positive reactivity to Hep C Antibody or is previously known to be Hep C  
positive (from clinical chart review using same criteria), then HCV RNA level in blood will 
be quantified as part of research procedure.     
  
MRI methods for Coronary Vasoreactivity: an index of CEF: Patients will undergo a 
detailed baseline MRI study of CEF in the fasting state using MRI methodology at rest and 
during continuous IHE as previously described 28. The MRI study will be used to measure 
coronary cross-sectional area (CSA), coronary flow velocity (CFV), and coronary blood 
flow (CBF) changes in response to IHE stress (continuous isometric handgrip for 4-8 min 
at 30% of each subject’s maximum, determined prior to entering the MRI), as previously 
reported29,28.   
  
Fasting:  Subjects will be asked to fast after midnight and delay eating breakfast and 
taking morning cardiovascular medicines until after the study procedure, which will be 
completed by noon.   
  
MRI analysis: MR images will be analyzed in blinded fashion without operator knowledge 
of time or treatment group for CEF (e.g. changes in CBF, CBV, and CSA) as previously 
validated and described 28. Baseline, 1-week and 6-week images will be analyzed at the 
same time for each subject by investigators blinded to time point of study to reduce 
variability and assure identical segments are analyzed at each time.  
  
Blood Draw and Analysis: Blood samples will be obtained from a peripheral vein using 
standard venipuncture techniques and will be sent for routine chemistries (basic 
metabolic panel and liver function tests, CBC) and lipids.  Biomarkers will be analyzed 
from blood specimens collected into collection tubes without anticoagulant and 
centrifuged within 1 hour after collection (to allow time for clotting) using a centrifuge with 
an integrated refrigeration system at 4°C/1000 g for 15 min and stored at -80°C.  
Analyses will be performed with ELISA or multiplexed ELISA including the following 
biomarkers of inflammation/activation/clotting: hsCRP, IL-6, TNFα, IFN-γ, PCSK9 activity 
and CD163.32 In addition, comprehensive lipid panel will be measured. To minimize 
variability of assays of longitudinal markers, the baseline, 1- and 6-week specimens of 
each individual will be analyzed on the same plate.   
  
Safety surveillance: Patients will undergo surveillance safety monitoring at 1 week, 4 
weeks (before 2nd dose of PCSK9 inhibitor is given to HIV+ participants) and 6 weeks 
that will include detailed history, physical exam and complete blood count. In the HIV+ 
group, liver and renal function tests will additionally be performed, and there will be a 10 
week safety follow up performed by phone 6 weeks after the last dose of drug is given.  
Members of the research team will review laboratory results from a safety standpoint.   
  
Follow up End-point Evaluation: After 1 week of the first dose and at 6 weeks after the 
first dose (and two weeks after the second dose) of PCKS9 inhibitor administration, 
subjects will undergo repeat clinical evaluation, lipid and inflammatory biomarker analysis, 
as well as coronary MRI with the same protocols used at baseline. In terms of MRI follow 
up exams (at weeks 1 and 6) coronary MRI will be repeated with an identical protocol and 
special attention taken to interrogate the same coronary segments as those studied at 


Effect of Evolocumab on Coronary Endothelial Function NCT03500302 
  
baseline, using anatomic landmarks of coronary ostia and branch vessels- as we have 
done in the past.  
  
List of study procedures (HIV+ group):  
  
1) Visit 1 (Screening Visit): includes Informed Consent, History and physical 
examination, vital signs (temperature, blood pressure, heart rate, weight, height), 
blood draw (CBC, CMP, Lipid panel, Hepatitis C Antibody Test if HCV status is 
unknown, HCV Quant PCR if known HCV positive, serum biomarkers of 
inflammation (above). MRI Screening questionnaire, cardiac MRI, If patient 
qualifies (based on MRI and entry criteria), the subject will receive PCSK9 inhibitor 
(this will be administered by a qualified study team member)  
Visit 2 (Baseline Visit) Subject will return for medical history reviewed for 
changes, concomitant medications, vital signs, 1st Dose of Evolocumab will be 
given by study team.  
Visit 3 (1 Week after Evolocumab is started): Subject will return for physical 
examinations, concomitant medications, vital signs (temperature, blood pressure, 
heart rate, weight), monitor for adverse events, blood draw (CBC, CMP, Lipid 
panel, serum biomarkers of inflammation/activation/clotting: hsCRP, IL-6, TNFα, 
IFN-γ, PCSK9 activity), MRI Screening questionnaire, cardiac MRI  
Visit 4: Subject will return 4 weeks after initial dose for safety assessment and to 
receive 2nd and final dose of evolucomab, review concomitant medications, and 
monitor for adverse events, measurement of vital signs (temperature, blood 
pressure, heart rate, weight).  
Visit 5 (6 Weeks after Evolocumab started) Subject will return 6 weeks after 
initial PCSK9 inhibitor given for physical examination, concomitant medications, 
vital signs (temperature, blood pressure, heart rate, weight), monitor for adverse 
events, blood draw (CBC, CMP, Lipid panel, serum biomarkers of inflammation), 
cardiac MRI.  Subjects will receive a phone call follow for safety assessment at 
week 10.   
  
Early stopping rules  
   
  
Participants who experience significant symptoms or who develop significant laboratory 
abnormalities will be evaluated and the scheduled second (final) study drug dose withheld. 
Participants who experience significant symptoms will be evaluated and those or others 
who develop new laboratory abnormalities will be reviewed and labs possibly repeated.  If 
any of the following criteria are met (CBC<2000, platelets<50,000, Hct<27%, GFR 
<30ml/min or a >50% reduction in GFR compared to baseline values, and LFTs >3x upper 
limit of normal), the test would be repeated. If confirmed on repeat, the second (and final) 
dose of the drug would not be given (HIV+ group). If the abnormality resolves, study drugs 
would be given at the same or lower dose. If the abnormality does not resolve, then the 
case will be reviewed for discontinuation from the study. Based on the clinical status, 
severity of the problem, and reversal of symptoms/laboratory findings, a decision will be 
made as to whether the study drug (2nd and final dose) can be started under close 
observation (weekly surveillance) or the patient withdrawn from the study. For every study 
participant who withdraws, we plan to recruit an additional subject so that the overall 
sample size of those completing the study is close to 20-25 subjects in each group. 


Effect of Evolocumab on Coronary Endothelial Function NCT03500302 
  
Participants who wish to end participation in the trial at any time may do so upon request 
without penalty.   
   
b. Description of what happens to participants receiving therapy when study ends 
or if a participant’s participation in the study ends prematurely.  
  
Participants withdrawn from receiving the scheduled second (final) dose of 
evolocumab due to an adverse experience will be followed by the Investigator until the 
outcome is determined.  Every effort will be made to follow the subject for the full study 
period as per the schedule of study visits.  
  
4. 
Inclusion/Exclusion Criteria  
  
  
Inclusion Criteria (HIV positive):  
  
A. Participants of either gender who are ≥21 years of age (no upper age limit),   
B. HIV positive and taking stable ART (no change in ART regimen in last 3 months)  
C. Clinically controlled HIV viral load (plasma HIV RNA concentration  
≤100copies/mL)  
D. Abnormal CEF on MRI at baseline (<5% change in CSA during IHE as compared to 
resting        value).  
E. Lipids at screening visit: Fasting LDL-C >70 mg/dL; fasting TG<500 mg/dL       F. 
Permission of attending physician  
  
Exclusion criteria:   
  
A. Patients unable to understand the risks, benefits, and alternatives of 
participation and unable to give meaningful consent,   
B. Patients with contraindications to MRI such as implanted metallic objects,  
cardiac pacemakers, and cerebral clips,   
C. History of a recent cardiovascular or cerebrovascular event or procedure (e.g. 
myocardial infarction, stroke, transient ischemic attack, angioplasty, CABG 
surgery) during the past 90 days.  
D. Subjects with prior exposure to evolocumab or another PCSK9 inhibitor.  
E. Pregnant women or breastfeeding women. Women of childbearing potential 
(even if using oral contraceptive agents) or intention to breastfeed. Pregnancy 
status will be determined by performing a urine pregnancy test.   
F. History of alcoholism or drug addiction according to the Diagnostic and 
Statistical Manual of Mental Disorders (DSM) IV criteria within 12 months prior 
to screening. Use of any recreational drugs within 6 months prior to screening. 
G.  Renal impairment defined by estimated glomerular filtration rate <45ml/min.  
H. Moderate-severe hepatic disease (elevation in hepatic transaminases >3x upper 
limit of normal) or direct bilirubin >3.0 X ULN at screening.  
I. CD4<200 cell/mm3 in the HIV+ subject group  


Effect of Evolocumab on Coronary Endothelial Function NCT03500302 
  
J. Congestive heart failure, New York Heart Association functional class IV.  
K. Poorly controlled hypertension at screening visit (defined as the average of two 
systolic blood pressure (BP) measurements greater than 180 mm Hg or the 
average of two diastolic BP measurements greater than 110 mm Hg).  
L. History of allergic or anaphylactic reaction to any therapeutic or diagnostic 
monoclonal antibody (IgG protein) or molecules made of components of 
monoclonal antibodies.   
M. Active phase hepatitis. Stable patients with hepatitis B or C infection >2 years 
before randomization are eligible.  
N. Subjects who are HCV antibody positive that have detectable HCV RNA levels.   
O. Latex allergy  
  
  
  
  
5. 
Study Statistics  
  
a. Primary outcome variable. Change in endothelial function,specifically, change 
in coronary cross sectional area (CSA) from rest to that during IHE stress, from 
baseline to one week and from baseline to six weeks.  
b. Secondary outcome variables.   
(i) Change in coronary artery blood flow (CBF) (from rest to IHE 
stress (as ml/min and as % rest) from baseline to one week and 
from baseline to six weeks.  
(ii) Inflammatory markers (hsCRP), LDL cholesterol at 1 and 6 weeks 
and change in these measures between baseline and 1 week and 
baseline and 6 weeks.   
  
To make full use of the data, changes in CEF from baseline to 1- and 6-weeks will be 
analyzed, changes in inflammatory biomarkers and lipids (hsCRP and LDL cholesterol) 
from baseline to 1- and 6-weeks. Also, the relationship between change in inflammatory 
markers and lipids from baseline to 1 and to 6 weeks and change in CEF between baseline 
and 1 and 6 weeks will be quantified.   
  
Safety endpoints: metabolic panel and complete blood count, withdrawal due to 
sideeffects SAEs and all AEs  
  
c. Statistical plan including sample size justification and interim data analysis.  
  
This is a pilot study to understand the effect size, if any, of the initiation of PCSK9 
antibody on coronary endothelial function (CEF) and the relationship between any change 
in CEF and change in inflammatory mediators.  However, it is possible, based on prior 
studies conducted by us and others that a significant change in CEF will be observed and 
it is very likely that we will observe changes in inflammatory markers and mediators over 
the six week study period.  The principal outcome of this observational study of the effects 


Effect of Evolocumab on Coronary Endothelial Function NCT03500302 
  
of evolocumab on CEF and inflammatory mediators in subjects with abnormal CEF is the 
change in CSA from rest to IHE at 1 and 6 weeks.  We chose to study the change in CSA 
because it 1.) reflects both macrovascular changes related to the endothelial-dependent 
IHE stressor, 2.) CEF reflected by CSA change is significantly depressed in HIV+ subjects 
compared to healthy subjects 3.) is reproducible over this proposed time period, and 4.) 
because endothelial function is an independent predictor of atherosclerotic progression 
and clinical events 33-37. The 6 week time was chosen to minimize confounding events 
occurring over longer times and because improvements in endothelial function are present 
in as short as 1 day to 6 weeks following the initiation of statin38. We will also collect CEF 
measures at 1 week to evaluate safety and detect whether a short term acute CEF effect 
is present. Drugs that improve cardiovascular outcomes improve endothelial function in 
fewer than 8 weeks39. An increase in the IHECSA response in subjects to approximately 
30% of that of healthy subjects does not assume complete normalization of CEF in 
participants with evolocumab but, instead, an increase that would be biologically 
significant and consistent with the changes in endothelial function observed with 
medications shown to reduce cardiovascular outcomes. For example, a landmark study 
demonstrated that statins improve CEF in CAD patients to approximately half of 
normal/maximal responses 40. In studies of subjects with CAD risk factors, comparisons 
are typically made with baseline or placebo measures and such studies consistently show 
that statins and ACE inhibitors improve abnormal endothelial function by ~50% or more in 
CAD patients 41-44. A similar 50% increase in endothelial function was also observed in 
HIV+ people treated for 8 weeks with statins 45. Thus based on the existing literature of 
the impact of established cardiovascular medications (statins, ACE-I) on endothelial 
function and based on our observations of differences in coronary endothelial function 
between HIV+ and HIV- individuals (CSA increases during IHE in healthy subjects 
+12%±5% (mean±SD) and does not increase in HIV+ or CAD patients, change of  -
2%±6% (mean±SD), we propose that there will be an increase to 4% CSA change with 
IHE (i.e. approximately 33% of the normal 15% increase in CSA with IHE we observe in 
healthy individuals) in the evolocumab-administered subjects.   We assume that at 6 
weeks:   
  
(1) Mean CSA will increase from -2% change from rest to IHE in subjects at baseline 
to +4% CSA change on evolocumab at 1- and 6 weeks.   
(2) Mean CBF will increase from -3% (CBF change from rest to IHE) in subjects at 
baseline to +15% (from rest to IHE, which represents improvement of CBF to about 
1/3 of normal "healthy" CBF response) in subjects on evolocumab at week 1 and 
week 6.   
(3) Standard deviation (variability) of 6% for study subjects  
  
 The variability is conservatively based on the mean standard deviation in CSA 
response observed in the HIV+ population and in CAD subjects. With a sample size of 18, 
we will have power of 90% (alpha=0.05, two-sided test) to detect such a difference in CSA-
IHE response between the baseline and study follow up time points (1- and 6 weeks)46. 
We will conservatively assume a 10% dropout rate over 6 weeks due to unwillingness to 
repeat MRI study. Therefore, we plan to study 20 participants.   
  
d. Early stopping rules.  
  


Effect of Evolocumab on Coronary Endothelial Function NCT03500302 
  
Participants who experience significant symptoms will be evaluated and those or 
others who develop laboratory abnormalities will have the study drug withheld. Based on 
the clinical status, severity of the problem, and reversal of symptoms/laboratory findings, 
a decision will be made as to whether the study drug can be restarted under close 
observation (weekly surveillance) or the patient withdrawn from the study. Participants 
who wish to end participation in the trial at any time may do so upon request without 
penalty. Because this is a short pilot study, we will attempt to recruit an additional subject 
for any that withdraws so that our target sample size of n=18 of those completing the study 
is met.