ascend-hf lbct final
Download
Report
Transcript ascend-hf lbct final
Acute Study of Clinical Effectiveness
of Nesiritide in Decompensated
Heart Failure
Adrian F. Hernandez, MD
On behalf of the ASCEND-HF Committees,
Investigators and Study Coordinators
Disclosure Information
Adrian F. Hernandez, MD
ASCEND-HF Trial
FINANCIAL DISCLOSURE:
Trial Sponsor: Scios Inc
Research funding from Johnson & Johnson
Honorarium from Amgen, Corthera
Full listing of disclosures at dcri.org
UNLABELED or UNAPPROVED USE: None
Study organization
Sponsor
Scios Inc.
Executive Committee
Independent DSMB
Chair: Rob Califf
Chris O’Connor (Co-PI), Randy Starling (Co-PI)
Paul Armstrong, Kenneth Dickstein,
Michel Komajda, Barry Massie, John McMurray,
Markku Nieminen, Jean Rouleau,
Karl Swedberg, Vic Hasselblad
Chair: Sidney Goldstein
Salim Yusuf,
David DeMets,
Milton Packer,
John Kjekshus
International Steering Committee
Clinical Event
Committee
Chair: John McMurray
ROW:
Coordinating center:
Johnson & Johnson
Global Clinical
Operations
DCRI
Adrian Hernandez,
Craig Reist,
Gretchen Heizer
North America
Academic Consortium:
(DCRI, C5, Jefferson,
Henry Ford, Canadian
VIGOUR Centre)
>800 Investigators and Study Coordinators at 398 Sites
Background
Acute heart failure is a major health problem responsible for
several million hospitalizations worldwide each year.
Standard therapy has not changed since 1970s and includes
diuretics and variable use of vasodilators or inotropes.
In 2001, nesiritide was approved by the FDA to reduce PCWP
and improve dyspnea, based on efficacy at 3 hrs.
However, in 2005 two meta-analyses raised concerns regarding
the risks of mortality and renal injury.
Subsequently, an independent panel* was convened by Scios
Inc and recommended that a clinical trial be conducted to
definitively answer the question of nesiritide’s safety and
efficacy.
*chaired by Eugene Braunwald
Design of ASCEND-HF: Guiding principles
Independent framework
Pragmatic trial model
• Focused
• Efficient study design
• Streamlined procedures
• Simple follow-up
Permissive enrollment criteria for broad population
Meaningful outcomes
Standard of care per local practice (“real world”)
Co-Primary objectives
To assess whether nesiritide vs placebo,
in addition to standard care provides:
• Significant improvement
in self-assessed dyspnea
at 6 or 24 hrs
using 7-point Likert scale
60
Markedly Better
Moderately Better
40
% Subjects
• Reduction in rate of
HF rehospitalization
or all-cause mortality
through Day 30
20
0
Minimally Better
No Change
Minimally Worse
Moderately Worse
20
40
Markedly Worse
Secondary and safety objectives
Secondary endpoints:
• Overall well-being at 6 and 24 hours
• Persistent or worsening HF and all-cause mortality from
randomization through discharge
• Number of days alive and outside of the hospital
• Cardiovascular rehospitalization and cardiovascular mortality
Safety endpoints:
• All cause mortality
• Renal: 25% decrease in eGFR at any time from study drug
initiation through Day 30
• Hypotension: As reported by investigator as symptomatic or
asymptomatic
Study design and drug procedures
Nesiritide
Acute HF < 24 hrs
from IV RX
24–168 hrs Rx
Placebo
Co-primary
endpoint:
Dyspnea relief
at 6 and 24 hrs
Co-primary
endpoint:
30-day death or
HF rehosp
All-cause
mortality
at 180
days
Double – blind placebo controlled
IV bolus (loading dose) of 2 µg/kg nesiritide or placebo
• Investigator’s discretion for bolus
• Followed by continuous IV infusion of nesiritide 0.01 µg/kg/min or placebo
for up to 7 days
Usual care per investigators including diuretics and/or other therapies as needed
Duration of treatment per investigator based on clinical improvement
Inclusion and exclusion criteria
Key inclusion criteria
Key exclusion criteria
Hospitalized for ADHF <24 hrs from Hypotension at baseline
IV treatment
(SBP <100 mm Hg or SBP<110
mm Hg with IV vasodilator)
Dyspnea at rest or with minimal
activity
Significant lung disease that could
interfere with interpretation of
1 clinical sign:
dyspnea
• Respiratory rate ≥ 20 breaths per
min
• Rales >1/3 bases
1 objective measure:
• CXR with pulmonary edema
• BNP ≥400 pg/mL or
NT-proBNP≥1000 pg/mL
• Prior EF <40% within 12 months
• PCWP > 20 mmHg
Acute coronary syndrome
Severe anemia or active bleeding
Treatment with levosimendan or
milrinone
Unstable doses of IV vasoactive
medication within 3 hours
Statistical methods
Study population: modified intention-to-treat based on receiving study
drug
Primary analysis:
• Co-primary endpoints tested using Bonferroni approach
• Composite of HF rehospitalization and all-cause mortality tested at
0.045 significance level
• Dyspnea tested at 0.005 level using Hochberg method:
Significant if both 6- and 24-hr assessment P values ≤0.005; or
If either 6- or 24-hr assessment P values ≤0.0025
Sample size determination:
• Based on composite endpoint: 89% power with 7000 patients using
chi-square test, assuming a placebo event rate of 14% and a relative
risk reduction of 18.6%
Enrollment
7141 patients
30 Countries & 398 Sites
Western Europe = 7%
35 sites
North America = 45%
214 sites
Latin America = 9%
39 sites
Central Europe = 14%
48 sites
Asia-Pacific = 25%
62 sites
>800 Investigators and Study Coordinators
Study population
Randomized (n=7141)
Placebo (n=3577)
• Did not receive study drug (n=66)
Hypotension (n=28)
Exclusion criteria (n=8)
Physician decision (n=6)
Participant withdrew consent (n=14)
Other reason (n=10)
Placebo MITT=3511
Nesiritide (n=3564)
• Did not receive study drug (n=68)
Hypotension (n=26)
Exclusion criteria identified (n=9)
Physician decision (n=6)
Participant withdrew consent (n=16)
Other reason (n=11)
Nesiritide MITT=3496
Baseline characteristics
Placebo (n=3511)
Nesiritide (n=3496)
67 (56, 76)
67 (56, 76)
Female (%)
34.9
33.4
Black or African American
15.0
14.7
124 (110, 140)
123 (110, 140)
Heart rate (beats/min)
82 (72, 95)
82 (72, 95)
Respiratory rate (breaths/min)
24 (21,26)
23 (21, 26)
Ischemic heart disease
60.8
59.5
Hypertension
72.6
71.8
Atrial fibrillation
37.7
37.4
Chronic respiratory disease
16.6
16.3
Diabetes
42.9
42.3
Age (yrs)
Systolic Blood Pressure (mmHg)
Medical History (%)
Continuous variables as median (IQR 25th, 75th); MITT population
Baseline characteristics
Placebo
(n=3511)
Nesiritide (n=3496)
LVEF <40% within 12 mths (%)
79.5
80.8
BNP (pg/mL)
989
Labs/Studies
NT pro-BNP (pg/mL)
Creatinine (mg/dL)
994
(543, 1782)
(544, 1925)
4461
4508
(2123, 9217)
1.2
(2076, 9174)
1.2
(1.0, 1.6)
(1.0, 1.5)
Loop diuretics
95.3
94.9
Inotropes
4.4
4.3
Vasodilators
14.1
15.7
Pre-randomization treatment (%)
Continuous variables as median (IQR 25th, 75th); MITT population
Co-Primary outcome: 30-day all-cause
mortality or HF rehospitalization
P=0.31
Hazard Ratio 0.93 (95% CI: 0.8,1.08)
12
10.1
10
9.4
Placebo
Nesiritide
8
%
6.1
6
4.0
4
6.0
3.6
2
0
30-day Death/HF
Rehospitalization
Risk Diff (95 % CI)
-0.7 (-2.1; 0.7)
30-day Death
-0.4 (-1.3; 0.5)
HF Rehospitalization
-0.1 (-1.2; 1.0)
30 day death/HF readmission subgroups
N=6836
All Subjects
Baseline SBP (mmHg)
< 123
≥ 123
N=3346
N=3490
Baseline Ejection Fraction
(%)
<40
≥ 40
N=4362
N=1187
Renal function- MDRD GFR
(mL/min/m2)
<60
≥ 60
N=3395
N=3093
History of CAD
No
Yes
N=3092
N=3742
History of Diabetes Mellitus
No
Yes
N=3923
N=2913
-10
Risk Difference <0: Favors Nesiritide;
Risk Difference >0: Favors Placebo
-5
0
5
Difference (%) and 95% Confidence Interval
10
30 day death/HF readmission subgroups
N=6836
All Subjects
Inotrope Use at
Randomization
No
Yes
N=6556
N=280
Vasodilators
None
Any IV Vasodilators
No IV Nitroglycerin
IV Nitroglycerin
N=5889
N=942
N=5943
N=892
Diuretics
No
Yes
N=691
N=6145
Study Drug Bolus
No
Yes
N=2609
N=4227
Time from Hosp to
Rand (hrs)
<15.5
≥15.5
N=3426
N=3410
-10
Risk Difference <0: Favors Nesiritide;
Risk Difference >0: Favors Placebo
-5
0
5
Difference (%) and 95% Confidence Interval
10
Co-Primary Endpoint: 6 and 24 hour dyspnea
6 Hours
24 Hours
70
70
P=0.030
60
42.1%
44.5%
50
13.4
15.0
40
40
% Subjects
60
30
20
10
28.7
29.5
0
34.1
32.8
38.6
37.8
22.1
21.2
9.5
8.6
3398
Placebo
3371
Nesiritide
30
20
10
10
30
21.7
20.3
3444
Placebo
3416
Nesiritide
40
50
60
30.4
20
30
40
27.5
0
10
20
% Subjects
50
66.1% P=0.007 68.2%
Markedly Better
Moderately Better
Minimally Better
Minimally Worse
Moderately Worse
Markedly Worse
No Change
Dyspnea at 6 and 24 Hours
Odds for Marked-Moderate Improvement
6 hours
All Subjects
24 hours
N=6860
N=6769
SBP
<123
≥123
N=3369
N=3491
N=3314
N=3455
GFR
<60
≥60
N=3494
N=3121
N=3349
N=3075
Ejection
Fraction
<40
≥40
N=4385
N=1186
N=4335
N=1171
CAD
No
Yes
N=3115
N=3743
N=3082
N=3685
Diabetes
No
Yes
N=3930
N=2930
N=3887
N=2882
0
1
20
1
OR <1: Favors Placebo; OR >1: Favors Nesiritide;
Odds Ratio of Markedly/Moderately vs. Other
2
Dyspnea at 6 and 24 Hours
Odds for Marked-Moderate Improvement
6 hours
24 hours
All Subjects
Inotropes
N=6860
N=6769
N=6574
N=286
N=6481
N=288
N=5912
N=943
N=5965
N=894
N=5835
N=929
N=5886
N=882
No
Yes
N=691
N=6169
N=679
N=6090
No
Yes
N=2612
N=4248
N=2564
N=4205
<15.5
≥15.5
N=3428
N=3432
N=3369
N=3400
No
Yes
None
Any IV Vaso
Vasodilators
No IV Nitro
IV Nitro
Diuretics
Study
Medication
Bolus
Time from
Hosp to
Rand
0
1
2
0
OR <1: Favors Placebo; OR >1: Favors Nesiritide;
Odds Ratio of Markedly/Moderately vs. Other
1
2
Secondary endpoints
Placebo
(n=3511)
Nesiritide
(n=3496)
Difference
(95% CI)
Pvalue
Persistent or worsening HF or
all-cause mortality through
discharge
4.8%
(165)
4.2%
(147)
-0.5
(-1.5 to 0.5)
0.30
Days alive and outside of
hospital through Day 30
20.7
20.9
0.2
(-0.13 to 0.53)
0.16
11.8%
(402)
10.9%
(372)
-0.9
(-2.4 to 0.6)
0.24
CV death or CV rehosp
through Day 30
Well Being at 6 hours*
Well Being at 24 hours*
Placebo
(n=3511)
Nesiritide
(n=3496)
P-value
40.3%
41.4%
0.32
63.7%
65.7%
0.02
*Combined response for moderately/markedly better
Renal Safety
Anytime Through Day 30
>25% decrease eGFR
Placebo
(n=3509)
Nesiritide
(n=3498)
P-value
29.5%
31.4%
0.11
1.0
1.0
0.9
0.9
0.8
0.8
0.7
0.7
0.6
0.5
0.4
0.6
0.5
0.4
0.3
0.3
0.2
0.2
0.1
0.1
0
0
2
4
6
Creatinine (mg/dL)
Nesiritide
Discharge or 10 day Creatinine
Cum Dist
Cum Dist
End of Treatment Creatinine
Placebo
8
0
0
2
4
6
Creatinine (mg/dL)
8
Hypotension
Risk
Difference
(95% CI)
Placebo
(n=3509)
Nesiritide
(n=3498)
Any hypotension
(Through Day 10/discharge)
15.3%
(538)
26.6%
(930)
(9.4 to 13.1)
Asymptomatic Hypotension
12.4%
(436)
21.4%
(748)
9.0
(7.2 to 10.7)
<.001
Symptomatic Hypotension
4.0%
(141)
7.1%
(250)
3.1
(2.1 to 4.2)
<.001
11.3
Pvalue
<.001
30-day mortality meta-analysis
Odds Ratio (95% CI)
Mills (N=163)
0.38 (0.05, 2.74)
Efficacy (N=127)
1.24 (0.23, 6.59)
Comparative (N=175)
1.43 (0.50, 4.09)
PRECEDENT (N=147)
0.59 (0.18, 2.01)
VMAC (N=498)
1.63 (0.77, 3.44)
PROACTION (N=237)
6.93 (0.89, 53.91)
COMBINED 30 day w/out ASCEND
1.28 (0.73, 2.25)
ASCEND-HF (N=7007)
0.89 (0.69, 1.14)
COMBINED with ASCEND
1.00 (0.76, 1.30)
0.1
1
10
Conclusions
Nesiritide did not reduce the rate of recurrent heart
failure hospitalization or death at 30 days.
Nesiritide reduced dyspnea to a modest degree,
consistent with previous findings but did not meet prespecified protocol criteria for statistical significance at 6
and 24 hours.
Nesiritide did not affect 30-day all cause mortality nor did
it worsen renal function as had been suggested by prior
meta-analyses of smaller studies.
Implications
Nesiritide can now be considered a safe therapy in
patients with acute heart failure.
Further analysis of ASCEND-HF is likely to permit better
understanding of acute heart failure and patient profiles
that may potentially benefit from nesiritide.
Our results from this large randomized trial emphasize
both the challenges of making therapeutic decisions on
inadequate evidence as well as the urgent need for
large, well-conducted trials capable of informing clinical
practice
Steering Committee
North America: Kirkwood F. Adams Jr MD; Javed Butler, MD;Maria Rosa
Costanzo, MD; Mark E. Dunlap, MD; Justin A. Ezekowitz, MBBCh, MSc; David
Feldman, MD, PhD; Gregg C. Fonarow, MD; Stephen S. Gottlieb, MD, MHS; James
A. Hill, MD, MS; Judd E. Hollander, MD; Jonathan G. Howlett, MD; Michael
Hudson, MD; Mariell L. Jessup, MD; Serge Lepage, MD; Wayne C. Levy, MD;
Naveen Pereira, MD; W.H. Wilson Tang, MD; John R. Teerlink, MD; David J.
Whellan, MD; Clyde W. Yancy, MD
Europe: Stefan D. Anker, MD, PhD; Dan Atar, MD; Alexander Battler, MD; Ulf
Dahlstrom, MD, PhD; Aleksandras Laucevicius, MD; Marco Metra, MD; Alexander
Parkhomenko, MD; Piotr Ponikowski, MD, PhD; Jindrich Spinar, MD; Svetla
Torbova, MD; Filippos Triposkiadis, MD;Vyacheslav Mareev, MD; Adriaan A.
Voors, MD, PhD; Faiez Zannad, MD, PhD
Latin America: Rodrigo Botero, MD; Nadine Clausell, MD; Ramón Corbalán, MD;
Rafael Diaz, MD; Gustavo Méndez Machedo
Asia Pacific: Ping Chai, MD; Wen-Jone Chen, MD; Henry Krum, MBBS, PhD;
Sanjay Mittal, MD; Byung Hee Oh, MD; Supachai Tanomsup, MD; Richard W.
Troughton, MD, PhD; YueJin Yang, MD;