|Year : 2019 | Volume
| Issue : 1 | Page : 14-18
Effect of beraprost sodium on pulmonary hypertension due to left ventricular systolic dysfunction: Protocol for a randomized controlled clinical trial
Li Wang1, Yu-Qi Chen2, Liang-Ping Zhao2, Xian-Song Chang1, Xiang Liu2, Wen-Jing Wang2, Jian-Chang Chen2, Wei-Ting Xu2
1 Department of Cardiology; Department of Emergency, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
2 Department of Cardiology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
|Date of Submission||19-Nov-2018|
|Date of Acceptance||27-Feb-2019|
|Date of Web Publication||25-Mar-2019|
Department of Cardiology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province
Source of Support: None, Conflict of Interest: None
Background and objectives: Beraprost sodium is mainly adapted to peripheral chronic arterial occlusive disease. However, the efficacy and safety of beraprost sodium in patients with pulmonary hypertension (PH) due to left ventricular systolic dysfunction (PH-HFrEF) remain unknown. The main objective of this study is to ascertain the efficacy and safety of beraprost sodium in the treatment of PH-HFrEF.
Subjects and methods: In this prospective, multi-center, randomized, controlled clinical trial, 462 consecutively recruited patients with PH-HFrEF are randomly assigned to receive routine treatment only or routine treatment in combination with oral administration of beraprost sodium 1 μg/kg for 1 year. All patients are followed up at 3, 6, 9 and 12 months after treatment. Systolic pulmonary artery pressure and left ventricular ejection fraction are assessed by echocardiography, and exercise tolerance is assessed by a 6-minute walk test. Cardiac events are also recorded. This trial was approved by the Medical Ethics Committee of the Second Affiliated Hospital of Soochow University (approval number: JD-LK-2017-021-02). Patient recruitment began in February 2018. Analysis of primary outcome measure will be completed in September 2021, and the study will be finished in September 2021.
Outcome measures: Outcome measures are assessed at baseline and at 3, 6, 9 and 12 months after treatment. The primary outcome measure is the reduction rate of systolic pulmonary artery pressure. The secondary outcome measures are the incidence of major adverse cardiac events, left ventricular ejection fraction, and 6-minute walking distance.
Discussion: Results of this study will provide evidence to validate whether application of beraprost sodium based on routine treatment can further reduce pulmonary artery pressure, improve cardiac function, reduce the incidence of heart events, and finally determine whether beraprost sodium is suitable for the treatment of PH-HFrEF.
Trial registration: This trial was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR-IPR-17012961) on October 12, 2017.
Keywords: beraprost; pulmonary hypertension; heart failure; pulmonary artery pressure; ejection fraction; exercise tolerance; prognosis; randomized controlled trial
|How to cite this article:|
Wang L, Chen YQ, Zhao LP, Chang XS, Liu X, Wang WJ, Chen JC, Xu WT. Effect of beraprost sodium on pulmonary hypertension due to left ventricular systolic dysfunction: Protocol for a randomized controlled clinical trial. Clin Trials Degener Dis 2019;4:14-8
|How to cite this URL:|
Wang L, Chen YQ, Zhao LP, Chang XS, Liu X, Wang WJ, Chen JC, Xu WT. Effect of beraprost sodium on pulmonary hypertension due to left ventricular systolic dysfunction: Protocol for a randomized controlled clinical trial. Clin Trials Degener Dis [serial online] 2019 [cited 2019 Jul 17];4:14-8. Available from: http://www.clinicaltdd.com/text.asp?2019/4/1/14/254107
| Introduction|| |
Pulmonary hypertension (PH) is a refractory disease with high cost and poor prognosis including five groups according to clinical presentation, pathological findings, hemodynamic characteristics, and treatment strategy. PH due to left ventricular systolic dysfunction (PH-HFrEF) is common with morbidity and mortality rates., PH-HFrEF is characterized by backward transmission of filling pressures due to impaired left ventricular systolic function with the increased pulmonary artery wedge pressure, and may further lead to right ventricle overload and right ventricular failure. At present, in addition to the treatment for left ventricular failure, there is still a lack of other ways to further reduce patient's pulmonary artery pressure and improve the whole heart function.
Beraprost is the first chemically stable and orally active prostacyclin analogue, and has antiplatelet and vessel-dilating effects. It is mainly used to reverse intermittent claudication and reduce the pain and cold symptoms caused by peripheral chronic arterial occlusive disease. A small sample-sized study including severe primary pulmonary hypertension showed that oral administration of beraprost may result in long-lasting clinical and hemodynamic improvements. The other two randomized controlled trials mainly selecting primary pulmonary hypertension patients showed that beraprost improves the exercise capacity that persists up to 3–6 months. But, there were no hemodynamic improvements or long-term outcome benefits.,
The pathogenesis of PH-HFrEF is completely different from that of primary pulmonary hypertension, so different therapies are used. There is a lack of related study on the use of beraprost in patients with PH-HFrEF. In this study, we gave beraprost sodium orally to patients with PH-HFrEF on the basis of routine treatment to investigate the efficacy and safety of this therapy.
The objectives of this study are to investigate whether beraprost sodium in combination with routine treatment can further reduce pulmonary artery pressure, improve cardiac function, and reduce the incidence of heart events in patients with PH-HFrEF, and evaluate the adverse drug reactions.
| Methods/Design|| |
Study design and setting
This is a prospective, multi-center, randomized, controlled clinical trial conducted at the Second Affiliated Hospital of Soochow University and the Seventh People's Hospital of Suzhou, China. This trial was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR-IPR-17012961) on October 12, 2017. The flow chart of this trial is given in [Figure 1]. The study protocol was developed based on the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines (Additional file 1[Additional file 1] ).
|Figure 1: Flow chart of the study.|
Note: PH-HFrEF: Pulmonary hypertension due to left ventricular systolic dysfunction; sPAP: systolic pulmonary artery pressure; LVEF: left ventricular ejection fraction; MACE: major adverse cardiac events; NT-proBNP: N-terminal pro-brain natriuretic peptide.
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Consecutively hospitalized patients with heart failure are included in this study.
Male or female patients aged 18 to 85 years are examined by echocardiography to determine whether there is left ventricular systolic dysfunction (left ventricular ejection fraction < 45%) and PH (systolic pulmonary artery pressure > 40 mmHg). The PH-HFrEF is defined as the left ventricular ejection fraction < 45% and systolic pulmonary artery pressure (sPAP) > 40 mmHg. All measurements are performed following the recommendations of the American Society of Echocardiography.,
Patients with shock, hemorrhagic disease, severe hepatic insufficiency, acute stage of myocardial infarction, pregnancy, malignant tumor, or other types of pulmonary hypertension (such as idiopathic, connective tissue diseases, drugs, thromboembolic, chronic lung disease, portal hypertension, and congenital heart disease) are excluded.
N-terminal pro-brain natriuretic peptide, leukocyte, hemoglobin, platelets, creatinine, alanine aminotransferase, glutamic oxalate aminotransferase, and serum lipid profiles including triglyceride, total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol are assessed using standard methods. Demographic and clinical characteristics of the recruited patients are collected from hospital case records and include age, sex, cigarette smoking status, hypertension, diabetes mellitus, and principal diagnosis. Patient's height (m) and body weight (kg) in light clothing are measured, and body mass index (kg/m2) is calculated.
Grouping and administration
After providing informed consent, the selected PH-HFrEF patients were randomly divided into routine treatment only and beraprost sodium + beraprost sodium groups.
Patients with PH-HFrEF are given beraprost sodium (Beijing Tede Pharmaceutical Co. Ltd., Beijing, China) orally for 1 year (1 μg/kg per day, three times of administration) on the basis of routine treatment including diuretics, spironolactone, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, βblockers, and digoxin. If there are no complications such as shock, severe bleeding, or severe liver function damage, the dosage of beraprost sodium is not changed.
Outcome measures are assessed at baseline and at 3, 6, 9 and 12 months after treatment. These include general indexes (aortic systolic pressure, diastolic pressure, heart rate, and rhythm, New York Heart Association cardiac function classification, electrocardiogram), echocardiographic indexes (sPAP and left ventricular ejection fraction), 6-minute walking distance, and blood parameters (N-terminal pro-brain natriuretic peptide, creatinine, alanine aminotransferase, glutamic oxalate aminotransferase, leukocyte, hemoglobin, and platelet).
Primary outcome measure
The primary outcome is the reduction rate of sPAP at 12 months after treatment compared with baseline. The reduction rate of sPAP is (sPAP at baseline – sPAP at 12 months after treatment)/sPAP at baseline ×100%.
Secondary outcome measures
The secondary outcome measures are the incidence of major adverse cardiac events (MACEs), left ventricular ejection fraction and 6-minute walking distance. The MACEs include cardiac death, heart failure readmission, myocardial infarction, and new onset of atrial fibrillation.
The time frame and measures are listed in [Table 1].
Adverse events including severe hemorrhage (intracerebral hemorrhage, gastrointestinal hemorrhage, pulmonary hemorrhage), shock and hepatic insufficiency (alanine aminotransferase exceeded the normal upper limit by three times), are recorded. If severe adverse reactions occur, the investigators will report the details and provide urgent treatment. Whether the adverse events are drug-related is determined according to the medical history, clinical manifestations, and auxiliary examinations.
According to the primary outcome measure, we hypothesized that the reduction rate of sPAP was 45% in the routine treatment + beraprost sodium group and 30% in the routine treatment group. Taking α = 0.05, power = 90%, and withdrawal rate = 10%, the total sample size calculated by PASS 11 software (NCSS, Silver Spring, MD, USA) was 231 cases in each group.
According to the secondary outcome measures, we hypothesized that the incidence of MACE was 10% in the beraprost sodium group, 20% in the routine treatment group. Taking α = 0.05, power = 90%, and withdrawal rate = 10%, the total sample size calculated by PASS 11 software was 191 cases in each group.
Therefore, the total sample size required for this study was 231 cases in each group.
The final data will be analyzed by SPSS 17.0 for Windows (SPSS Inc., Chicago, IL, USA). The chi-square test will be used for analyzing count data, and Student's t-test (normal distribution) or Mann-Whitney U test (non-normal distribution) will be used for analyzing quantitative data.
The difference of reduction rate of sPAP between the routine treatment and routine treatment + beraprost sodium groups will be analyzed by Student's t-test (normal distribution) or Mann-Whitney U test (non-normal distribution). The chi-square test will be used to analyze the incidence of MACE between the two groups. The Kaplan-Meier method (i.e., log-rank test) will be used for survival analysis and Cox regression will be used to evaluate independent predictors of MACE occurrence.
Data summarization and case verification are conducted every 3 months. All adverse events are recorded and properly handled. Investigators should trace the adverse events until they are properly resolved or stable, and report them to the ethics committee in time. Principal investigators should review all adverse events accumulatively every 3 months, and convene a meeting among investigators to assess the risks and benefits of the study if necessary.
Case report forms are prepared to standardize the investigation and survey techniques and to improve the working ability and responsibility of the investigators.
Ethics and dissemination
This trial was approved by the Medical Ethics Committee of the Second Affiliated Hospital of Soochow University, China (approval number: JD-LK-2017-021-02) and are undertaken in accordance with Good Clinical Practice guidelines and the Declaration of Helsinki. Informed consent is obtained from the patients before enrollment (Additional file 2 [Additional file 2] ). Patient recruitment was initiated in February 2018. Analysis of primary outcome measure will be completed in September 2021, and the study will be finished in September 2021. Dissemination plans include presentations at scientific conferences and publication in scientific journals.
| Discussion|| |
PH-HFrEF is different from other types of PH in terms of pathogenesis and management. Unlike heterozygous BMPR2 mutations accounting for approximately 75% of familial pulmonary arterial hypertension, no specific genetic linkage has been identified for PH-HFrEF., PH is common in patients with chronic heart failure. Up to 60% of patients with severe left ventricular systolic dysfunction develop PH, and almost all patients with severe symptomatic mitral valve disease have PH whether or not with heart failure.,
Management of PH-HFrEF is a systematic work. Treatment for group 1 PH (idiopathic, heritable, drugs and toxins induced, associated with connective tissue disease, etc.) in the European Society of Cardiology (ESC) and the European Respiratory Society (ERS) guidelines does not apply to patients with PH-HFrEF. Most of the clinical findings showed that PH-specific therapies (e.g., endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, soluble guanylyl cyclase stimulators) had no effects on PH-HFrEF and some could even be regarded as harmful.,, General therapies for heart failure including diuretics, digoxin, angiotensin-converting enzyme inhibitors and β-blockers are recommended for the treatment of PH-HFrEF. Furthermore, identifying and treating possible causes of heart failure, such as coronary artery disease, cardiomyopathy, and heart valve disease, is important.
Beraprost, a stable and oral prostacyclin analogue, is recommended for peripheral chronic arterial disease. Like prostacyclin, beraprost acts on the prostacyclin receptor in platelets and vascular smooth muscle, activates adenylate cyclase, increases intracellular cAMP concentration, inhibits Ca2+ influx and thromboxane A2 production, and thus plays the antiplatelet and vasodilatory effects. In addition, beraprost can increase the endothelial nitric oxide synthase and nitric oxide production in mouse and bovine aortic endothelial cells, and suppress tumor necrosis factor-α expression in human monocytes via mitogen-activated protein kinase pathway, which are all beneficial to vascular diseases.
Our pilot study with a small sample size showed that oral administration of beraprost sodium on the basis of routine treatment may reduce patient's sPAP, increase left ventricular ejection fraction and 6-minute walking distance. There were no cardiac death, myocardial infarction, shock, severe bleeding, and severe impairment of liver function, which indicate the great efficacy and safety of beraprost in these patients. Therefore, we designed this randomized controlled trial to investigate whether the addition of beraprost sodium on the basis of routine treatment can further reduce pulmonary artery pressure, improve cardiac function, reduce the incidence of heart events in patients with PH-HFrEF.
We are currently recruiting participants.
Additional file 1: SPIRIT Checklist.
Additional file 2: Model consent form (Chinese).
We would like to thank all subjects who have agreed to participate in the study.
Chief investigator of this study: LPZ; coinvestigators: LW, YQC, XSC, XL, WJW, JCC, WTX; concept and design of the study: LW, YQC; manuscript drafting: LW; patient recruitment: XSC, XL, WJW; follow-ups: JCC, WTX; approval of final manuscript for publication: all authors.
Conflicts of interest
The authors declare no conflicts of interest.
No current funding sources for this study.
Institutional review board statement
The protocol was approved by the Medical Ethics Committee of the Second Affiliated Hospital of Soochow University (approval number: JD-LK-2017-021-02).
Declaration of patient consent
The authors certify that they will obtain all appropriate patient consent forms. In the forms, the patients will give their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
This study protocol was reported in line with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines.
The statistical methods of this study were reviewed by the biostatistician of the Soochow University in China.
Copyright transfer agreement
The Copyright License Agreement has been signed by all authors before publication.
Data sharing statement
Individual participant data that underlie the results reported in this article, after deidentification will be in particular shared. Study protocol and informed consent form will be available. The data will be available immediately following publication without end date. Results will be disseminated through presentations at scientific meetings and/or by publication in a peer reviewed journal. Anonymized trial data will be available indefinitely at www.figshare.com.
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Externally peer reviewed.
Open access statement
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| References|| |
Galiè N, Humbert M, Vachiery JL, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J
Oudiz RJ. Pulmonary hypertension associated with left-sided heart disease. Clin Chest Med
Schmeisser A, Schroetter H, Braun-Dulleaus RC. Management of pulmonary hypertension in left heart disease. Ther Adv Cardiovasc Dis
Farber HW, Gibbs S. Under pressure: pulmonary hypertension associated with left heart disease. Eur Respir Rev
Alonso-Coello P, Bellmunt S, McGorrian C, et al. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th
ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest
. 2012;141(2 Suppl):e669S-690S.
Vizza CD, Sciomer S, Morelli S, et al. Long term treatment of pulmonary arterial hypertension with beraprost, an oral prostacyclin analogue. Heart
Galiè N, Humbert M, Vachiéry JL, et al. Effects of beraprost sodium, an oral prostacyclin analogue, in patients with pulmonary arterial hypertension: a randomized, double-blind, placebo-controlled trial. J Am Coll Cardiol
Barst RJ, McGoon M, McLaughlin V, et al. Beraprost therapy for pulmonary arterial hypertension. J Am Coll Cardiol
Chan AW, Tetzlaff JM, Gotzsche PC, et al. SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials. BMJ
Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr
Ommen SR, Nishimura RA, Hurrell DG, et al. Assessment of right atrial pressure with 2-dimensional and Doppler echocardiography: a simultaneous catheterization and echocardiographic study. Mayo Clin Proc
Soubrier F, Chung WK, Machado R, et al. Genetics and genomics of pulmonary arterial hypertension. J Am Coll Cardiol
. 2013;62(25 Suppl):D13-21.
Badesch DB, Champion HC, Sanchez MA, et al. Diagnosis and assessment of pulmonary arterial hypertension. J Am Coll Cardiol
. 2009;54(1 Suppl):S55-66.
Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J
Redfield MM, Chen HH, Borlaug BA, et al. Effect of phosphodiesterase-5 inhibition on exercise capacity and clinical status in heart failure with preserved ejection fraction: a randomized clinical trial. JAMA
Kalra PR, Moon JC, Coats AJ. Do results of the ENABLE (Endothelin Antagonist Bosentan for Lowering Cardiac Events in Heart Failure) study spell the end for non-selective endothelin antagonism in heart failure? Int J Cardiol
Bonderman D, Ghio S, Felix SB, et al. Riociguat for patients with pulmonary hypertension caused by systolic left ventricular dysfunction: a phase IIb double-blind, randomized, placebo-controlled, dose-ranging hemodynamic study. Circulation
Cheli M, Vachiery JL. Controversies in pulmonary hypertension due to left heart disease. F1000Prime Rep
Guazzi M, Borlaug BA. Pulmonary hypertension due to left heart disease. Circulation
Niwano K, Arai M, Tomaru K, et al. Transcriptional stimulation of the eNOS gene by the stable prostacyclin analogue beraprost is mediated through cAMP-responsive element in vascular endothelial cells: close link between PGI2 signal and NO pathways. Circ Res
Wang WL, Kuo CH, Chu YT, Huang CH, Lam KP, Huang SK, Jong YJ, Kuo YT, Hung CH. Prostaglandin I(2) analogues suppress TNF-α expression in human monocytes via mitogen-activated protein kinase pathway. Inflamm Res