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Steroids In caRdiac Surgery Trial (SIRS Trial)

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ClinicalTrials.gov Identifier: NCT00427388
Recruitment Status : Unknown
Verified July 2014 by Richard Whitlock, McMaster University.
Recruitment status was:  Active, not recruiting
First Posted : January 29, 2007
Last Update Posted : August 4, 2014
Canadian Institutes of Health Research (CIHR)
Information provided by (Responsible Party):
Richard Whitlock, McMaster University

Brief Summary:
SIRS trial is a large simple study in which high-risk patients undergoing cardiac surgery requiring the use of cardiopulmonary bypass (CPB) are randomly allocated to receive a pulse dose of Methylprednisolone or a matching placebo. Cardiopulmonary bypass initiates a systemic inflammatory response that facilitates development of post-operative complications. SIRS will confirm or deny the potential clinical benefits of suppressing this response through the use of systemic steroids. Specifically, does 250 mg of intravenous Methylprednisolone given twice, once on anesthetic induction and again on CPB initiation, result in improved early survival and less myocardial infarction in high-risk cardiac surgery patients requiring CPB?

Condition or disease Intervention/treatment Phase
Cardiac Surgical Procedures Cardiopulmonary Bypass Systemic Inflammatory Response Syndrome Drug: Methylprednisolone Other: Placebo Phase 4

Detailed Description:

Cardiopulmonary bypass (CPB) is a commonly performed surgical procedure with over 500,000 per year in North America. CPB initiates a systemic inflammatory response characterized by both cell and protein activation. Platelets, neutrophils, monocytes, macrophages, coagulation, fibrinolytic, and kallikrein cascades all take part in what results in increased endothelial permeability, vascular, and parenchymal damage. These inflammatory pathways facilitate development of post-operative complications including thrombosis, myocardial injury and infarction, respiratory failure, renal and neurological dysfunction, bleeding disorders, altered liver function and ultimately, multiple organ failure.

In an attempt to minimize the deleterious effects of CPB, investigators have tested a variety of strategies in cardiac surgery ranging from the complete avoidance of CPB, to the use of biocompatible circuits and pharmacologic agents to abrogate the systemic response. Investigators have consistently demonstrated the efficacy of steroids as the most potent anti-inflammatory agent for use during CPB. In fact, from the available evidence, the 2004 AHA guidelines for coronary artery bypass grafting (CABG) "support liberal prophylactic use in patients undergoing extracorporeal circulation". However, the trials that do exist within this literature are focused on biochemical endpoints and are insufficiently powered to make conclusions on hard clinical endpoints. Our pilot RCT, SIRS I, demonstrated the efficacy of a low dose steroid protocol in the suppression of this inflammatory cascade. We hypothesize that this low dose protocol will yield clinical benefit while avoiding the potential adverse effects of steroids which are known to be dose dependent.

The primary aim of the SIRS trial is to determine if perioperative pulse dose Methylprednisolone results in improved early survival and less myocardial infarction in cardiac surgery requiring CPB. Additional secondary aims of the SIRS trial are to determine the effect of steroids on other clinical outcomes including length of stay, new onset atrial fibrillation, transfusion requirements, infectious, wound, and gastrointestinal complications.

The design of the SIRS trial is a prospective multicentre international double-blind placebo controlled randomized clinical trial. The sample size of 7500 patients will have 80% to 90% power to detect a 20-30% RRR for the primary outcome with an α=0.05 (two-sided), anticipating a 6% rate of death in the control arm. Our aim is to have 85 international centers participate which, recruiting at 5 patients per month, would complete recruitment in 36 months. This will be a large trial with a simple design and objective outcomes.

A sub-group of patients will be enrolled in a renal sub-study. This sub-study will determine if the risk of acute kidney injury is lower in patients treated with intravenous steroid versus placebo, if steroids lead to better preservation of kidney function six months after cardiac surgery, and whether the impact of steroid exposure differs in patients with and without pre-operative chronic kidney disease.

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 7507 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary Purpose: Treatment
Official Title: Phase IV Study of Perioperative Steroid's Effects on Death or MI in High-Risk Patients Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass
Study Start Date : June 2007
Actual Primary Completion Date : February 2014
Estimated Study Completion Date : August 2014

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Heart Surgery

Arm Intervention/treatment
Experimental: Treatment
500 mg of methylprednisolone divided into two intravenous doses of 250 mg each, one during anesthetic induction and the other on CPB initiation
Drug: Methylprednisolone
Given by IV in 2 doses (250 mg each dose for a total of 500 mg)

Placebo Comparator: Placebo
500 mg of matching placebo (normal saline solution) divided into two intravenous doses of 250 mg each, one during anesthetic induction and the other on CPB initiation
Other: Placebo
Given in 2 IV doses (approximately 4 ml of 0.9% normal saline solution in each dose)

Primary Outcome Measures :
  1. Mortality at 30 days [ Time Frame: 30 days post-randomization ]
  2. Composite [ Time Frame: 30 days post-randomization ]
    Incidence of the composite outcome of death, myocardial infarction, stroke, renal failure (KDIGO Stage III acute kidney injury, 2012 Kidney Disease Improving Global Outcomes (KDIGO) guidelines), or respiratory failure within 30 days

Secondary Outcome Measures :
  1. MI or Mortality at 30 days [ Time Frame: 30 days post-randomization ]
    Composite of death or significant myocardial infarction within 30 days post-randomization

  2. Mortality at 6 months [ Time Frame: 6 months post-randomization ]
    All-cause mortality at 6 months post-randomization

  3. Atrial Fibrillation [ Time Frame: 30 days post-randomization ]
    New onset atrial fibrillation within 30 days post-randomization

  4. Transfusion Requirements [ Time Frame: 24 hours post-surgery ]
    Transfusion requirements within first 24 hours post-operative

  5. Chest Tube Output [ Time Frame: 24 hours post-surgery ]
    Chest tube output within first 24 hours post-operative

  6. ICU and Hospital Length of Stay [ Time Frame: Hospital Discharge ]
    Length of ICU stay and hospital stay

  7. Infection [ Time Frame: 30 days post-randomization ]
    Infection within 30 days post-randomization

  8. Delirium [ Time Frame: 3 days post-surgery ]
    Delirium at day 3 post-operative

  9. Wound Complication [ Time Frame: 30 days post-randomization ]
    Wound complication within 30 days post-randomization

  10. GI Hemorrhage [ Time Frame: 30 days post-randomization ]
    GI hemorrhage or GI perforation within 30 days post-randomization

  11. Insulin Use [ Time Frame: 24 hours post-surgery ]
    Post-operative insulin use within the first 24 hours after surgery

  12. Peak Blood Glucose [ Time Frame: 24 hours post-surgery ]
    Peak blood glucose within the first 24 hours after surgery

Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  1. Age greater than 18 years
  2. Require CPB for any cardiac surgical procedure (such as CABG, Valve, Aorta, or combined procedures)
  3. Must have a EuroSCORE ≥ 6
  4. Provide written informed consent

NOTE: For participating sites in India, China and Hong Kong, the following eligibility criteria will be applied:

  1. Age greater than 18 years
  2. Require CPB for any cardiac surgical procedure (such as CABG, Valve, Aorta, or combined procedures)
  3. Must have at least one of the following:

    1. EuroSCORE greater than or equal to 4 and undergoing valvular surgery
    2. EuroSCORE greater than or equal to 6 and undergoing any other cardiac surgery procedure (i.e. CABG, Aorta)
  4. Provide written informed consent

Exclusion Criteria:

  1. Use of systemic corticosteroids
  2. History of bacterial or fungal infection in last 30 days
  3. Allergy/intolerance to corticosteroids
  4. Will receive Aprotinin
  5. Previous participation in study

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT00427388

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Canada, Ontario
Hamilton General Hospital
Hamilton, Ontario, Canada, L8L 2X2
Sponsors and Collaborators
Population Health Research Institute
Canadian Institutes of Health Research (CIHR)
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Principal Investigator: Salim Yusuf, MD, DPhil PHRI
Principal Investigator: Kevin Teoh, MD, MSc McMaster University
Principal Investigator: Richard P Whitlock, MD, MSc McMaster University
Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
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Responsible Party: Richard Whitlock, Assistant Professor, McMaster University
ClinicalTrials.gov Identifier: NCT00427388    
Other Study ID Numbers: SIRS 2007
First Posted: January 29, 2007    Key Record Dates
Last Update Posted: August 4, 2014
Last Verified: July 2014
Keywords provided by Richard Whitlock, McMaster University:
Cardiac Surgical Procedures
Cardiopulmonary Bypass
Systemic inflammatory Response Syndrome
Myocardial Infarction
Randomized Clinical Trial
Additional relevant MeSH terms:
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Systemic Inflammatory Response Syndrome
Pathologic Processes
Methylprednisolone Acetate
Methylprednisolone Hemisuccinate
Prednisolone acetate
Prednisolone hemisuccinate
Prednisolone phosphate
Anti-Inflammatory Agents
Autonomic Agents
Peripheral Nervous System Agents
Physiological Effects of Drugs
Gastrointestinal Agents
Hormones, Hormone Substitutes, and Hormone Antagonists
Neuroprotective Agents
Protective Agents
Antineoplastic Agents, Hormonal
Antineoplastic Agents