Progression of Coronary Atherosclerosis in Asymptomatic Diabetic Subjects (PROCEED)

Progression of Coronary Atherosclerosis in Asymptomatic Diabetic Subjects: Evaluation of the Role of CT Coronary Angiography and Novel Bio-markers of Endothelial Dysfunction and Vascular Inflammation

The purpose of the study is to identify a sub-group of diabetic patients at higher risk of progression of coronary disease and also more likely to suffer from heart attack/angina and heart failure. The total number of patients to be recruited in this study will be 250 with type-2 diabetes but no known heart disease. These patients will have an objective measure of the function of the lining of the arteries, CT scan of the arteries of the heart and an ultrasound scan of the heart and arteries of the neck done at baseline along with blood tests for identification new markers of malfunction of the lining and inflammation of the arteries. Patients will be followed up at 18 months. During the follow-up visit, in addition to the blood tests, the CT scan of the heart arteries and ultrasound of the heart and arteries of the neck will be repeated to assess progression of the non-calcified, calcified and mixed plaques in the coronary arteries.

Study Overview

• Status: Unknown
• Conditions: Coronary Artery Disease; Type 2 Diabetes

Detailed Description

Hypothesis: We hypothesise that a combination of CT coronary angiography, ultrasound of the heart and of the arteries of the neck, evaluation of expression of genetic markers and bio-markers in the blood will help identify diabetic patients at highest risk of heart disease progression,that can result in angina, heart attacks, heart failure and cardiovascular deaths.

Previous studies using coronary calcium scanning in diabetic patients showed that those with the greatest progression in calcified plaque in the coronary arteries were at the highest risk for heart attacks. However, coronary calcium scans only identify the calcified plaque and are not able to pick up non-calcified, cholesterol rich plaques. Cholesterol rich non-calcified plaques are more often associated witn acute heart attacks. CT coronary angiography can identify both calcified and non-calcified plaques and can therefore add significantly to our predictive ability. Certain chemical substances (biomarkers) measured in blood indicate the severity of plaque burden and inflammation in the coronary arteries. A combination of CT coronary angiography, expression of genetic markers, measure of function of the cells lining the blood vessels and biomarkers can help to identify diabetic patients at highest risk of heart attacks, allowing us to start appropriate risk reduction treatments in those patients. In previous studies with coronary artery calcium, patients suffering from heart attacks were those who also had a higher progression of coronary artery calcium (CAC) score. In diabetics, in particular, patients with poor control of their blood glucose also had greater progression of the CAC score. In order to test the validity of our hypothesis, we have decided to base our study on a population of established diabetics with difficult to control blood pressure, high cholesterol and chronic complications of the small blood vessels, i.e. involvement of the retina (back of the eye) and peripheral nerves as well as protein in the urine. Patients with chronic complications of diabetes are known to have higher incidence of heart disease as well.

Methodology and Timetable: Patients will be recruited from Diabetes clinics of NHS hospitals in North West London.

If eligible for the trial, an informed consent will be obtained from the patients and their general practitioner will be subsequently informed about their participation in the trial. Once recruited into the trial, a CT coronary angiogram (CTCA, CT of the arteries of the heart), ultrasound scan of the heart and carotid arteries of the neck as well as a measure of endothelial function will be performed at the Wellington Hospital in St. Johns Wood, London within 1-2 weeks. At the same time, blood samples will also be obtained for bio-markers. A report of the CTCA will then be forwarded to the consultant in-charge of the patient's care as well as to the GP.

If a narrowing of moderate degree (70%) is noted on the CT angiogram, the patient will then be brought back to the Wellington Hospital within 2 weeks for a heart perfusion scan which evaluates the relative discrepancies in flow of blood to the heart muscle and helps plan further management.

If there is significant reduction in blood flow noted in the perfusion scan,patients will be referred back to the consultants for further clinical management.

During their first visit to the Wellington Hospital for the CT scan, blood samples will be taken and stored on-site for biomarker analysis.

Patients will be followed up after 18 months from the time of recruitment into the trial,when a second CTCA, ultrasound of the arteries of the neck will be performed to assess the degree of progression of calcium and cholesterol deposits within the coronary arteries and thickness of the lining of the arteries in the neck in addition to blood sample collection for bio-markers.

Patients with significant narrowing of coronary arteries (>70%) requiring a stent to be inserted in the first scan will be excluded from follow up. Patients with normal coronary arteries on the initial scan also will be excluded from the follow-up.

• Study Type: Observational
• Enrollment (Anticipated): 250

Contacts and Locations

Study Locations

• United Kingdom
  • London, United Kingdom, NW3 2QG
    • Recruiting
    • Royal Free Hospital
    • Contact: Shreenidhi M Venuraju, MRCP; Phone Number: +442074835062; Email: shreenidhimv@gmail.com
    • Principal Investigator: Roby Rakhit, MD FRCP
    • Sub-Investigator: Miranda Rosenthal, MRCP PhD
    • Sub-Investigator: Devaki R Nair, MSc MRCPath FRCPath
    • Sub-Investigator: Pierre Bouloux, MD
    • Sub-Investigator: Dipesh Patel, MRCP PhD
  • London, United Kingdom, EC1A 7BE
    • Not yet recruiting
    • Barts Health NHS Trust
    • Contact: Shreenidhi M Venuraju, MRCP; Phone Number: +442074835062; Email: shreenidhimv@gmail.com
    • Principal Investigator: Rajiv A Amersey, MD FRCP
  • London, United Kingdom, EN5 3DJ
    • Recruiting
    • Barnet Hospital
    • Contact: Shreenidhi M Venuraju, MRCP; Phone Number: +442074835062; Email: shreenidhimv@gmail.com
    • Principal Investigator: Mark Cohen, FRCP PhD
  • London, United Kingdom, NW1 2BU
    • Not yet recruiting
    • University College London Hospitals
    • Contact: Shreenidhi M Venuraju, MRCP; Phone Number: +442074835062; Email: shreenidhimv@gmail.com
    • Principal Investigator: Sarita Naik, DM MRCP
  • Middlesex
    • London, Middlesex, United Kingdom, NW10 7NS
      • Recruiting
      • Central Middlesex Hospital
      • Contact: Shreenidhi M Venuraju, MRCP; Phone Number: +442074835062; Email: shreenidhimv@gmail.com
      • Principal Investigator: Daniel Darko, MRCP

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 35 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Patients with type 2 diabetes recruited from hospital clinics and one community faith based cardiovascular disease prevention clinic run under the aegis of a lipidologist

Description

Inclusion Criteria:

• Established T2DM with or without micro-vascular complications of diabetes (retinopathy, peripheral neuropathy and/or micro-albuminuria)

No history of coronary artery disease (CAD)

Exclusion Criteria:

• 1. Estimated GFR <45 2. Pregnant women 3. Age < 35 years 4. Atrial fibrillation 5. Known allergy to iodine contrast 6. CAC score >1000 Agatston Units

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort
Asymptomatic type 2 diabetes; Patients without previous history of coronary artery disease

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Greater than 20% increase in plaque volume	Plaque volume will be measured by both manual and semi-quantitative methods	18 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Greater than 20% increase in coronary artery calcium score	Coronary artery calcium scoring will be performed using a semi-quantitative method.	18 months

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Correlation between increase in plaque volume with levels of biomarkers	Correlate plaque progression with various bio-markers	18 months
Correlation between carotid IMT measurements and coronary plaque	Once at baseline and then during follow-up	18 months
Incidence of major adverse cardiovascular events (MACE) during the 18-month follow-up period. MACE is defined as incidence of cardiac death, non-fatal myocardial infarction, STEMI and NSTEMI, unstable angina, late revascularization and onset of angina	Through questionnaires and medical records	18 months

Collaborators and Investigators

• Sponsor: British Cardiac Research Trust
• Collaborators: Lund University; Royal Free Hospital NHS Foundation Trust; London North West Healthcare NHS Trust; Barnet and Chase Farm Hospitals NHS Trust; Diabetes and Obesity Research Network; Health Diagnostic Laboratory, Inc.
• Investigators: Study Chair: Roby Rakhit, MD FRCP, Royal Free Hospital NHS Foundation Trust; Study Director: Avijit Lahiri, MRCP FACC, Wellington Hospital; Principal Investigator: Daniel Darko, MRCP, Central Middlesex Hospital; Principal Investigator: Mark Cohen, PhD FRCP, Barnet Hospital; Principal Investigator: Rajiv A Amersey, MD FRCP, Whipps Cross Hospital; Principal Investigator: Sarita Naik, DM MRCP, University College London Hospital

Publications and helpful links

General Publications

• Anand DV, Lim E, Lahiri A, Bax JJ. The role of non-invasive imaging in the risk stratification of asymptomatic diabetic subjects. Eur Heart J. 2006 Apr;27(8):905-12. doi: 10.1093/eurheartj/ehi441. Epub 2005 Aug 8.
• Anand DV, Lahiri A, Lim E, Hopkins D, Corder R. The relationship between plasma osteoprotegerin levels and coronary artery calcification in uncomplicated type 2 diabetic subjects. J Am Coll Cardiol. 2006 May 2;47(9):1850-7. doi: 10.1016/j.jacc.2005.12.054. Epub 2006 Apr 19.
• Anand DV, Lim E, Darko D, Bassett P, Hopkins D, Lipkin D, Corder R, Lahiri A. Determinants of progression of coronary artery calcification in type 2 diabetes role of glycemic control and inflammatory/vascular calcification markers. J Am Coll Cardiol. 2007 Dec 4;50(23):2218-25. doi: 10.1016/j.jacc.2007.08.032. Epub 2007 Nov 19.
• Fredrikson GN, Anand DV, Hopkins D, Corder R, Alm R, Bengtsson E, Shah PK, Lahiri A, Nilsson J. Associations between autoantibodies against apolipoprotein B-100 peptides and vascular complications in patients with type 2 diabetes. Diabetologia. 2009 Jul;52(7):1426-33. doi: 10.1007/s00125-009-1377-9. Epub 2009 May 12.
• Jeevarethinam A, Venuraju S, Weymouth M, Atwal S, Lahiri A. Carotid intimal thickness and plaque predict prevalence and severity of coronary atherosclerosis: a pilot study. Angiology. 2015 Jan;66(1):65-9. doi: 10.1177/0003319714522849. Epub 2014 Feb 26.
• Venuraju SM, Lahiri A, Jeevarethinam A, Cohen M, Darko D, Nair D, Rosenthal M, Rakhit RD. Duration of type 2 diabetes mellitus and systolic blood pressure as determinants of severity of coronary stenosis and adverse events in an asymptomatic diabetic population: PROCEED study. Cardiovasc Diabetol. 2019 Apr 23;18(1):51. doi: 10.1186/s12933-019-0855-8.

Study record dates

Study Major Dates

• Study Start: September 1, 2012
• Primary Completion (ANTICIPATED): July 1, 2015
• Study Completion (ANTICIPATED): July 1, 2017

Study Registration Dates

• First Submitted: April 8, 2014
• First Submitted That Met QC Criteria: April 8, 2014
• First Posted (ESTIMATE): April 10, 2014

Study Record Updates

• Last Update Posted (ESTIMATE): May 19, 2015
• Last Update Submitted That Met QC Criteria: May 18, 2015
• Last Verified: May 1, 2015

More Information

Terms related to this study

• Keywords: Diabetes; coronary artery disease; Cardiac computed tomography; Computed tomographics coronary angiography; Plaque progression
• Additional Relevant MeSH Terms: Pathologic Processes; Heart Diseases; Cardiovascular Diseases; Vascular Diseases; Arteriosclerosis; Arterial Occlusive Diseases; Disease Attributes; Coronary Artery Disease; Myocardial Ischemia; Coronary Disease; Disease Progression; Atherosclerosis
• Other Study ID Numbers: BCRT/3277/PROCEED