Cardiovascular Improvements With MV ASV Therapy in Heart Failure (CAT-HF)

Cardiovascular Improvements With Minute Ventilation-targeted ASV Therapy in Heart Failure (CAT-HF)

The aim of the study is to compare the effects of MV targeted ASV in addition to optimized medical therapy versus optimized medical therapy alone at 6 months in patients with acute decompensated HF. The study will also assess changes in functional parameters, biomarkers, quality of life (QOL), and sleep.

Study Overview

• Status: Terminated
• Conditions: Acute Decompensated Heart Failure; Sleep Disordered Breathing
• Intervention / Treatment: Device: MV ASV; Drug: Optimized Medical Treatment

Detailed Description

This study is a randomized, unblinded, multi-center trial with parallel group design, with subjects randomized to either control (optimized medical therapy for chronic heart failure) or active treatment (optimized medical therapy plus use of MV-targeted ASV) in a 1:1 ratio.

• Study Type: Interventional
• Enrollment (Actual): 126
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Germany
  • Bad Oeynhausen, Germany
    • Heart and Diabetes Center - North Rhine-Westphalia (HDZ-NRW)
• United States
  • Alabama
    • Huntsville, Alabama, United States, 35801
      • The Heart Center
  • California
    • Los Angeles, California, United States, 90073
      • VA Greater Los Angeles Healthcare System
  • Colorado
    • Denver, Colorado, United States, 80220
      • VA Medical Center
  • Georgia
    • Macon, Georgia, United States, 31201
      • Mercer University
  • Illinois
    • Chicago, Illinois, United States, 60611
      • Northwestern University
  • Maryland
    • Baltimore, Maryland, United States, 21201
      • University of Maryland
  • Missouri
    • Kansas City, Missouri, United States, 64111
      • St. Luke's Hospital of Kansas City
    • Saint Louis, Missouri, United States, 63110
      • Washington University School of Medicine
  • North Carolina
    • Durham, North Carolina, United States, 27710
      • Duke University Medical Center
  • Ohio
    • Cincinnati, Ohio, United States, 45267
      • University of Cincinnati
  • Pennsylvania
    • Hershey, Pennsylvania, United States, 17033
      • Penn State Hershey
    • Philadelphia, Pennsylvania, United States, 19107
      • Jefferson Heart Institute
  • Virginia
    • Norfolk, Virginia, United States, 23507
      • Sentara Cardiovascular Research Institute
  • Washington
    • Seattle, Washington, United States, 98195
      • University of Washington

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 21 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients 21 years or older
• Patients with prior clinical diagnosis of heart failure (HFrEF or HFpEF), or de novo diagnosis of HFpEF indicated by a local BNP≥300 pg/mL or NT pro-BNP≥1200 pg/mL on admission without systolic blood pressure >180 mmHg or atrial fibrillation, or diagnosis of HFrEF indicated by documented evidence of prescribed beta-blockers and ACE-inhibitors or ARBs for at least 4 weeks prior to admission

• Hospital admission for acute decompensated HF as determined by:

  • Dyspnea at rest or with minimal exertion

    • AND At least two of the following signs and symptoms:
  • Orthopnea
  • Pulmonary rales beyond basilar
  • Chest congestion on x-ray
  • BNP≥300pg/mL or NT pro-BNP≥1200pg/mL
  • Pulmonary capillary wedge pressure (PCWP) ≥25mmHg during current hospitalization
• Presented to hospital or clinic at least 24 hours prior to consent
• Patient stable enough to stop oxygen use for duration of polygraphy test or have access to dual lumen cannula for polygraphy test
• Sleep disordered breathing (SDB) documented by polygraphy with an AHI≥15 events/hour
• Patient is able to fully understand study information and sign a consent form

Exclusion Criteria:

• Right-sided heart failure without left-sided heart failure
• Sustained systolic blood pressure <80 mmHg at baseline
• Acute coronary syndrome within 1 months of randomization
• Active myocarditis
• Complex congenital heart disease
• Constrictive pericarditis
• Non-cardiac pulmonary edema
• Clinical evidence of digoxin toxicity
• Need for mechanical hemodynamic support at time of randomization
• Oxygen saturation ≤85% at rest during the day or at start of nocturnal oximetry recording or regular use of oxygen therapy (day or night)
• COPD exacerbation as the primary reason for hospital admission
• Current use (within 4 weeks of study entry) of any PAP-therapy (eg, fixed, bi-level, or APAP)
• Life expectancy < 1 year for diseases unrelated to HF
• Transient ischemic attack (TIA) or Stroke within 3 months prior to randomization
• CABG procedure within 3 months prior to randomization, or planned to occur during study period
• CRT implant within 3 months prior to randomization , or planned to occur during study period
• VAD implant planned to occur during study period
• Heart transplant list Status 1a or 1b
• Status post-transplant or LVAD
• Prescribed inotrope therapy anticipated at discharge
• Chronic Dialysis
• Known amyloidosis, hypertrophic obstructive cardiomyopathy, arteriovenous fistulas
• Primary hemodynamically significant uncorrected valvular heart disease (obstructive or regurgitant) with planned intervention within 6 months of randomization
• Pregnant, or planning to become pregnant
• Cannot tolerate ASV treatment during run-in
• Cannot perform 6MWT at baseline
• Occupation as a commercial driver or pilot and plan to be performing these activities during the study period
• Inability to comply with planned study procedures
• Participation in pharmaceutical or treatment-related clinical study within 1 month of study enrollment

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: MV ASV+OMT; Minute Ventilation-targeted adaptive servo-ventilation therapy plus optimized medical treatment	Device: MV ASV; Minute ventilation-targeted servo-ventilation therapy.; Other Names: AutoSet CS; VPAP Adapt; Drug: Optimized Medical Treatment; Beta Blockers, ACE inhibitor or ARB, loop diuretics and/or spironolactone as appropriate, statin if indicated, aspirin and/or warfarin if indicated
Active Comparator: OMT only; Optimized Medical Treatment for heart failure in accordance with applicable guidelines (ACCF/AHA Guideline for the Management of Heart Failure and HFSA Heart Failure Guidelines.	Drug: Optimized Medical Treatment; Beta Blockers, ACE inhibitor or ARB, loop diuretics and/or spironolactone as appropriate, statin if indicated, aspirin and/or warfarin if indicated

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Global Rank Endpoint	A rank order response based on survival free from CV hospitalization and improvement in functional capacity measured by 6MWD. All participants were first ranked by time to death, then ranked by time to CV hospitalization, and then ranked by percentage change in 6MWD. For time to event measures (time to death and time to hospitalization), the shorter the amount of time, the lower the rank assigned to that participant. For percentage changes in 6MWD, the smaller the percentage change, the lower the rank assigned to that participant. Each component was then combined to create a rank value that ranged between 0 and 100. Overall, higher rank values are associated with better outcomes.	Baseline, 6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Six-minute Walk Distance	Change in functional parameters as measured by 6-minute walk test (6MWT)	Change from Baseline to 6 months
NT Pro-BNP	Change in neurohumoral activation as measured by N-terminal pro b-type natriuretic peptide.	Change from Baseline to 6 months
Kansas City Cardiomyopathy Questionnaire (KCCQ)	The 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.	Change from Baseline to 6 months
Biomarkers - Inflammation	Biomarkers of inflammation reported as troponin I ultra-sensitive	Change from Baseline to 6 months
Biomarkers - Cardiovascular	Biomarkers of cardiovascular function reported as hs-CRP	Change from Baseline to 6 months
Biomarkers - Renal Function	Biomarkers of renal function reported as creatinine	Change from Baseline to 6 months
ECHO Parameters - LVEF	Echocardiographic parameters, including LVEF (left ventricular ejection fraction) and LVESVI (left ventricular end-systolic volume index) for patients with HFrEF (heart failure with reduced ejection fraction), and E/e' (ratio between early mitral inflow velocity and mitral annular early diastolic velocity) for patients with HFrEF or HFpEF (heart failure with preserved ejection fraction).	Change from Baseline to 6 months
ECHO Parameters - LVESVI	Echocardiographic parameters, including LVEF (left ventricular ejection fraction) and LVESVI (left ventricular end-systolic volume index) for patients with HFrEF (heart failure with reduced ejection fraction), and E/e' (ratio between early mitral inflow velocity and mitral annular early diastolic velocity) for patients with HFrEF or HFpEF (heart failure with preserved ejection fraction).	Change from Baseline to 6 months
ECHO Parameters - E/e' Ratio	Echocardiographic parameters, including LVEF (left ventricular ejection fraction) and LVESVI (left ventricular end-systolic volume index) for patients with HFrEF (heart failure with reduced ejection fraction), and E/e' (ratio between early mitral inflow velocity and mitral annular early diastolic velocity) for patients with HFpEF (heart failure with preserved ejection fraction).	Change from Baseline to 6 months
Win Ratio	Patients in the new treatment and control groups are formed into matched pairs based on their risk profiles. For each matched pair, the new treatment patient is labeled a 'winner' or a 'loser' depending on who had a CV death first. If that is not known, they are labeled a 'winner' or 'loser' depending on who had a HF hospitalization first. Otherwise they are considered tied. The win ratio is the total number of winners divided by the total numbers of losers.	6 months
Sleep Parameters	Sleep and sleep disordered breathing parameters (AHI, nocturnal hypoxemia)	Change from Baseline to 6 months
Number of Subjects With HF Hospitalization	Rates of hospitalization or urgent clinic visit for worsening of heart failure and for any reason	2 days, 1 week, 1, 2, 3, and 6 months
Death	Rate of Cardiovascular and all-cause death	2 days, 1 week, 1, 2, 3, and 6 months
Time Dead/Hospitalized	Total days dead or hospitalized at study end	6 months
DASI	The Duke Activity Status Index is a 12-item patient-reported outcome validated for the assessment of functional capacity based on the ability to perform everyday activities. With a total range of 0 to 58.20, a higher score indicates better quality of life.	Change from Baseline to 6 months
EQ-5D-5L Index	The EQ-5D-5L is a standardized self-report questionnaire that is used as a measure of health outcome. The EQ-5D-5L questionnaire is comprised of the following 5 dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems, and extreme problems. Responses were indexed using the EQ-5D-5L US value set to scale the 5 dimensions. A score of -0.109 indicates extreme problems for all dimensions and a score of 1.000 indicates no problems for all dimensions. Therefore, a higher score indicates better general health.	Change from Baseline to 6 months
PHQ-9	The PHQ-9 is the nine item depression scale of the Patient Health Questionnaire. The PHQ-9 is a self-administered instrument for screening, diagnosing, monitoring and measuring the severity of depression. The PHQ-9 incorporates DSM-IV depression diagnostic criteria with other leading major depressive symptoms into a brief self-report tool. The tool rates the frequency of the symptoms which factors into the following scoring severity index: 0 - Not at all, 1 - Several Days, 2 - More than Half the Days, 3 - Nearly Every Day. Total score can range from 0 to 27. A higher score indicates increased severity.	Change from Baseline to 6 months
PSQI	The Pittsburgh Sleep Quality Index is a 19-item subjective measurement of sleep. It is an effective instrument used to measure the quality and patterns of sleep in the older adult. It differentiates "poor" from "good" sleep by measuring seven areas: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication and daytime dysfunction over the last month. The subject self-rates each of these seven areas of sleep. The seven component scores are then added to yield a total score with a range of 0-21 points, "0" indicating no difficulty and "21" indicating severe difficulties in all areas.	Change from Baseline to 6 months
ESS	The Epworth Sleepiness Scale is a simple, 8-item self-administered questionnaire which provides a measurement of the subject's general level of daytime sleepiness. The individual is asked on a scale of 0-3 to score the likelihood of falling asleep in eight various situations. With a total range of 0 to 24, a higher score indicates increased severity.	Change from Baseline to 6 months

Collaborators and Investigators

• Sponsor: ResMed
• Collaborators: ResMed Foundation
• Investigators: Principal Investigator: Christopher O'Connor, MD, Duke University

Publications and helpful links

General Publications

• Piccini JP, Pokorney SD, Anstrom KJ, Oldenburg O, Punjabi NM, Fiuzat M, Tasissa G, Whellan DJ, Lindenfeld J, Benjafield A, Woehrle H, Blase A, O'Connor CM. Adaptive servo-ventilation reduces atrial fibrillation burden in patients with heart failure and sleep apnea. Heart Rhythm. 2019 Jan;16(1):91-97. doi: 10.1016/j.hrthm.2018.07.027. Epub 2018 Jul 27.
• O'Connor CM, Whellan DJ, Fiuzat M, Punjabi NM, Tasissa G, Anstrom KJ, Benjafield AV, Woehrle H, Blase AB, Lindenfeld J, Oldenburg O. Cardiovascular Outcomes With Minute Ventilation-Targeted Adaptive Servo-Ventilation Therapy in Heart Failure: The CAT-HF Trial. J Am Coll Cardiol. 2017 Mar 28;69(12):1577-1587. doi: 10.1016/j.jacc.2017.01.041. Erratum In: J Am Coll Cardiol. 2017 May 9;69(18):2355.
• Fiuzat M, Oldenberg O, Whellan DJ, Woehrle H, Punjabi NM, Anstrom KJ, Blase AB, Benjafield AV, Lindenfeld J, O'Connor CM. Lessons learned from a clinical trial: Design, rationale, and insights from The Cardiovascular Improvements with Minute Ventilation-targeted Adaptive Sero-Ventilation (ASV) Therapy in Heart Failure (CAT-HF) Study. Contemp Clin Trials. 2016 Mar;47:158-64. doi: 10.1016/j.cct.2016.01.001. Epub 2016 Jan 19.

Study record dates

Study Major Dates

• Study Start: December 1, 2013
• Primary Completion (Actual): December 1, 2015
• Study Completion (Actual): December 1, 2015

Study Registration Dates

• First Submitted: September 23, 2013
• First Submitted That Met QC Criteria: September 26, 2013
• First Posted (Estimate): October 1, 2013

Study Record Updates

• Last Update Posted (Actual): February 28, 2018
• Last Update Submitted That Met QC Criteria: January 29, 2018
• Last Verified: January 1, 2018

More Information

Terms related to this study

• Keywords: obstructive sleep apnea; heart failure; sleep apnea; central sleep apnea; congestive heart failure; sleep disordered breathing; chronic heart failure; acute decompensated heart failure; left-sided heart failure; heart failure decompensation; cheyne-stokes respiration
• Additional Relevant MeSH Terms: Pathologic Processes; Heart Diseases; Cardiovascular Diseases; Nervous System Diseases; Respiratory Tract Diseases; Apnea; Respiration Disorders; Sleep Disorders, Intrinsic; Dyssomnias; Sleep Wake Disorders; Heart Failure; Sleep Apnea Syndromes; Respiratory Aspiration
• Other Study ID Numbers: MA-12-12-01