Aldosterone Antagonist Therapy for Adults With Heart Failure and Preserved Systolic Function (TOPCAT)

• Composite Outcome of Cardiovascular Mortality, Aborted Cardiac Arrest, or Hospitalization for the Management of Heart Failure, Whichever Occurred First [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  

• Cardiovascular Mortality [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  
• Aborted Cardiac Arrest [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  First incidence of aborted cardiac arrest
  
  
• Hospitalization for the Management of Heart Failure [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  First incidence of a hospitalization for the management of heart failure
  
  
• All-cause Mortality [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  
• Composite Outcome of Cardiovascular Mortality or Cardiovascular-related Hospitalization (i.e., Hospitalization for Myocardial Infarction(MI), Stroke, or the Management of Heart Failure), Whichever Occurred First [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  
• Cardiovascular-related Hospitalization [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  Hospitalization for MI, stroke or the management of heart failure, whichever occurred first
  
  
• Total Hospitalizations (Including Repeat Hospitalizations) for the Management of Heart Failure [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  
• Composite Outcome of Sudden Death or Aborted Cardiac Arrest, Whichever Occurred First [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  
• New Onset Diabetes Mellitus, Among Subjects Without a History of Diabetes Mellitus at Baseline. [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  First incidence of new onset diabetes mellitus among subjects without a history of diabetes mellitus at baseline.
  
  
• Development of Atrial Fibrillation, Among Subjects Without a History of Atrial Fibrillation at Baseline. [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  First incidence of atrial fibrillation among subjects without a history of atrial fibrillation at baseline
  
  
• Myocardial Infarction [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  First incidence of myocardial infarction
  
  
• Stroke [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  First incidence of stroke
  
  
• Deterioration of Renal Function [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  First incidence of a deterioration of renal function. The TOPCAT protocol defines deterioration of renal function as occurring if a subject has a serum creatinine value which is at least double the baseline value for that subject, and is also above the upper limit of normal (assumed to be 1.0 mg/dL for females and 1.2 mg/dL for males.)
  
  
• Composite Outcome of Sudden Death, Aborted Cardiac Arrest, or Hospitalization for the Management of Ventricular Tachycardia, Whichever Occurred First [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  
• Quality of Life, as Measured by the Kansas City Cardiomyopathy Questionnaire. [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]

  Average post-baseline quality of life, taking into consideration baseline quality of life, treatment group, the time between the post-baseline measures, and the correlation between repeated measures within an individual.

  The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a 23-item, self-administered instrument that quantifies physical function, symptoms (frequency, severity and recent change), social function, self-efficacy and knowledge, and quality of life. Scores are transformed to a range of 0-100, in which higher scores reflect better health status. The KCCQ was administered at the following study visits: baseline, month 4, month 12 and annually thereafter.

  
  
• Quality of Life, as Measured by the EuroQOL Visual Analog Scale. [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]

  Average post-baseline quality of life, taking into consideration baseline quality of life, treatment group, the time between the post-baseline measures, and the correlation between repeated measures within an individual.

  The EuroQOL visual analog scale (EQ5D) is a single-item, self-administered instrument that quantifies current health status. Scores can range from 0-100, in which higher scores reflect better health status. The EQ5D was administered at the following study visits: baseline, month 4, month 12 and annually thereafter.

  
  
• Quality of Life, as Measured by McMaster Overall Treatment Evaluation Questionnaire. [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]

  Average post-baseline quality of life, taking into consideration baseline quality of life and treatment group.

  The McMaster Overall Treatment Evaluation questionnaire is a self-administered 3-item instrument that measures a patient's perception of change in their health-related quality of life since the start of therapy. The questionnaire consists of a single question - "Since treatment started, has there been any change in your activity limitation, symptoms and/or feelings related to your heart condition?" Scores can range from -7 to +7, and higher scores reflect better health status. The questionnaire was administered at the following study visits: month 4 and month 12. Valid translations of this questionnaire were only available for subjects enrolled in the United States, Canada and Argentina.

  
  
• Depression Symptoms, as Measured by Patient Health Questionnaire. [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]

  Average post-baseline depression, taking into consideration baseline depression, treatment group, the time between the post-baseline measures, and the correlation between repeated measures within an individual.

  The Patient Health Questionnaire (PHQ) is a 10-item, self-administered instrument for screening, diagnosing, monitoring and measuring the severity of depression. Scores can range from 0-27, in which lower scores reflect better mental health status. The PH-Q was administered at the following study visits: baseline, month 12 and annually thereafter. Valid translations of this questionnaire were only available for subjects enrolled in the United States and Canada.

  
  
• Hospitalization for Any Reason [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  First incidence of a hospitalization for any reason
  
  
• Potassium [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  Average post-baseline Potassium, taking into consideration baseline Potassium, treatment group, the time between the post-baseline measures, and the correlation between repeated measures within an individual.
  
  
• Serum Creatinine [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  Average post-baseline serum creatinine, taking into consideration baseline serum creatinine, treatment group, the time between the post-baseline measures, and the correlation between repeated measures within an individual.
  
  
• Sodium [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  Average post-baseline Sodium, taking into consideration baseline Sodium, treatment group, the time between the post-baseline measures, and the correlation between repeated measures within an individual.
  
  
• Chloride [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  Average post-baseline Chloride, taking into consideration baseline Chloride, treatment group, the time between the post-baseline measures, and the correlation between repeated measures within an individual.
  
  
• Estimated Glomerular Filtration Rate (GFR) [ Time Frame: Randomization through each subject's last semi-annual visit, up to a maximum of 6 years per subject. ]
  Average post-baseline GFR, taking into consideration baseline GFR, treatment group, the time between the post-baseline measures, and the correlation between repeated measures within an individual.
  
  

BACKGROUND:

Heart failure (HF) is a major cause of morbidity and mortality, particularly in older people. Indeed, it is the most common discharge diagnosis in patients older than 65 years. As the United States population ages, heart failure will continue to grow as a public health concern. Therapeutic trials of heart failure have dealt almost exclusively with patients who have systolic dysfunction. However, there is now an emerging awareness that nearly half of the patients with heart failure have preserved systolic function and that the survival of these patients is adversely affected. This study is a randomized clinical trial of a novel therapeutic approach, specifically the use of spironolactone, an aldosterone antagonist, in treating these patients. While this treatment has been shown to be useful in treating heart failure with reduced systolic function, it has not been studied in patients with preserved systolic function.

Patients with heart failure and preserved systolic function have a poor prognosis. The annual mortality rate is intermediate between the prognosis for those without heart failure and for those with heart failure and reduced systolic function. For instance, Family Health Study participants with heart failure and preserved systolic function had a mortality rate of 9% compared to 3% for their age- and gender-matched controls. The mortality rate was 19% in heart failure patients with reduced systolic function heart failure compared to 4% for their matched controls.

As heart failure develops, neurohormones are released that initially improve cardiac output but ultimately contribute to progression of left ventricular dysfunction. The renin-angiotensin-aldosterone system is an important part of this compensatory response. Aldosterone levels may rise to 20 times normal levels in heart failure and aldosterone contributes to the development of myocardial fibrosis. Spironolactone is a potassium-sparing diuretic that acts on the distal tubule, inhibiting sodium and potassium ion exchange. There are several potential beneficial actions, including prevention of cardiac fibrosis. A recent trial evaluated spironolactone in patients with systolic dysfunction heart failure. Spironolactone treatment caused a 30% reduction in mortality compared to placebo (p< 0.001). The improvement resulted from a reduction in all cause mortality. More recently, the Eplerenone Post-Myocardial Infarction (MI) study showed that this aldosterone antagonist significantly reduces mortality despite background treatment with an angiotensin-converting enzyme (ACE) inhibitor and beta-blocker. Advantages of using spironolactone in this study are that it is commercially available, inexpensive, and no longer under patent (therefore this study will not be done by industry). Also, there is a clear physiologic rationale for its use, and the side effect profile is well understood. The study enrolled subjects who had preserved systolic function with heart failure and who met clearly defined eligibility criteria that were selected to make the results widely generalizable to clinical practice.

DESIGN NARRATIVE:

This is a randomized, double-blinded, placebo-controlled trial of aldosterone antagonist therapy (15 mg dose spironolactone or placebo; titrated up to 30 or 45 mg/day) in 3,445 adult patients with heart failure and preserved systolic function. Patients were recruited from August 2006 through January 2012, treated, and will be followed through June 2013. Approximately 270 clinical sites in six countries were subcontracted by the clinical trial coordinating center. Subject visits to a clinical center will occur every four or six months. Data collected include demographic and clinical data, including the results of history and physical exams, laboratory and imaging data, repository specimens for special physiology studies, and genetic studies. Additionally, data regarding quality of life and compliance with assigned treatment will also be collected and assessed.