Anakinra to Prevent Post-infarction Remodeling (VCU-ART)

• Difference Between the 2 Arms in Change in End-diastolic Volume Indices and Ejection Fraction Values From Baseline to Follow up Exam at Cardiac Magnetic Resonance Imaging [ Time Frame: 10-14 weeks ] [ Designated as safety issue: No ]
• Difference Between the 2 Arms in Change in E/E' Ratios and Myocardial Performance (Tei) Indices From Baseline to Follow up Exam at Transthoracic Echo-color-Doppler Cardiac Exam [ Time Frame: 10-14 weeks ] [ Designated as safety issue: No ]
• Difference Between the 2 Arms in the Percentage of Patients With Any of the Following : a) End-systolic or End-diastolic Volume Index Increase >10%; b) Ejection Fraction Decrease >10%; c) E/E'>15 at Follow up [ Time Frame: 10-14 weeks ] [ Designated as safety issue: No ]
• Difference Between the 2 Arms in Change in Oxygen Uptake Kinetics From Baseline to Follow up Exam at Submaximal Cardiopulmonary Exercise Test [ Time Frame: 10-14 weeks ] [ Designated as safety issue: No ]
• Difference Between the 2 Arms in Change in the Number of Circulating Endothelial Progenitor Cells From Baseline to Follow up Exam [ Time Frame: 10-14 weeks ] [ Designated as safety issue: No ]
• Difference Between the 2 Arms in Change in Serum BNP Levels, C-reactive Protein, and Hemoglobin A1c% From Baseline to Follow up [ Time Frame: 10-14 weeks ] [ Designated as safety issue: No ]
• Difference Between the 2 Arms in the Incidence of Significant Cardiac Arrhythmias in the Acute Phase [ Time Frame: 48 hours ] [ Designated as safety issue: Yes ]
• Difference Between the 2 Arms in the Number of Adverse Effects Including a) All Events; b) All Events Requiring Unblinding of the Treatment; c) All Events Requiring Early Termination of the Intervention [ Time Frame: 10-14 weeks ] [ Designated as safety issue: Yes ]

Thousands of patients die daily from early and late complications of a heart attack (acute myocardial infarction, AMI). Patients surviving AMI remain at high risk of death from adverse cardiac remodeling (dysfunction and enlargement of the heart) leading to heart failure (weakening of the heart).

Current interventions proven to reduce adverse remodeling and progression to heart failure include early reperfusion (restoring blood flow to the heart muscle) and long-term use of medicines that block the effects of hormones (such as angiotensin II, norepinephrine and aldosterone) involved in adverse remodeling. Despite these treatments, however, many patients continue to develop heart failure within 1 year of AMI. These patients are at very high risk of death.

Numerous changes occur in the hearts of patients after AMI that lead to adverse remodeling. Ischemia (lack of oxygen) and infarction (cell damage) lead to increased interleukin-1 (IL-1) production in the heart. IL-1 plays a critical role in adverse cardiac remodeling by coordinating the inflammatory pathway (leading to wound healing) and apoptotic pathway (leading to cell death).

In opposition to IL-1 activity, the human body produces a natural IL-1 receptor antagonist that blocks the effects of IL-1. The drug form of this IL-1 receptor antagonist (anakinra) is currently FDA approved for the treatment of rheumatoid arthritis, an inflammatory disease characterized by excessive IL-1 activity. Experimental studies show that anakinra is able to prevent cardiac remodeling and improve survival in mice after AMI.

We hypothesize that anakinra will show similar benefits in human patients by preventing adverse remodeling and heart failure after AMI.

• Drug: Anakinra
  100 mg daily subcutaneous injection for 14 days
  Other Name: Kineret (TM)
• Drug: Placebo
  0.67 ml of NaCl 0.9% subcutaneously daily for 14 days

• Experimental: Anakinra
  Anakinra 100 mg given daily by subcutaneous injection for 14 days
  Intervention: Drug: Anakinra
• Placebo Comparator: Placebo
  0.67 ml of NaCl 0.9% solution
  Intervention: Drug: Placebo

Inclusion Criteria:

• Age >18 years
• Acute (<24 hours) onset of chest pain
• New or presumably new ST elevation on ECG
• Planned coronary angiography for percutaneous revascularization

Exclusion Criteria:

• Inability to give informed consent
• Late presentation (>24 hours)
• Unsuccessful revascularization or urgent coronary bypass surgery
• Hemodynamic instability
• End-stage congestive heart failure (AHA/ACC stage C/D, NYHA class IV)
• Preexisting severe LV dysfunction (LVEF<20%) or severe valvular disease
• Severe asthma
• Pregnancy ( pre-enrollment pregnancy test)
• Contraindications to cardiac MRI or cardiac angiography
• Severe coagulopathy (INR>2.0, Platelet count<50,000/mm3)
• Severe renal insufficiency (creatinine clearance <30 ml/min/m2)
• Recent (<14 days) use of anti-inflammatory drugs (NSAIDS excluded)
• Chronic inflammatory disease