Study to Compare Ferric Carboxymaltose With Placebo in Patients With Acute Heart Failure and Iron Deficiency (Affirm-AHF)

A Randomised, Double-Blind Placebo Controlled Trial Comparing the Effect of Intravenous Ferric Carboxymaltose on Hospitalisations and Mortality in Iron Deficient Patients Admitted for Acute Heart Failure (Affirm-AHF)

Study to Compare Ferric Carboxymaltose With Placebo in Patients With Acute Heart Failure and Iron Deficiency (Affirm-AHF)

Study Overview

• Status: Completed
• Conditions: Heart Failure; Iron Deficiency
• Intervention / Treatment: Drug: ferric carboxymaltose; Other: Normal saline 0.9%

Detailed Description

This is a randomised, double-blind, placebo-controlled Trial (RCT). The 52 weeks observation period following randomisation is considered appropriate to investigate the primary endpoint of recurrent HF hospitalisations and CV death. To evaluate the effect of intravenous ferric carboxymaltose (IV FCM) in iron deficient subjects with AHF, subjects will be enrolled during a hospital stay (Index hospitalisation) after the acute care treatment of the index event has been stabilised. All subjects will continue to receive their established standard therapy for HF and medical emergencies will be treated according to local routine.

• Study Type: Interventional
• Enrollment (Actual): 1132
• Phase: Phase 4

Contacts and Locations

Study Locations

• Argentina
  • Buenos Aires, Argentina, 1500
    • Hospital Universitario Austral
• Brazil
  • São Paulo, Brazil, 05403-900
    • InCor -Instituto do Coração HCFMUSP
• Croatia
  • Rijeka, Croatia
    • Clinical Hospital Center Rijeka
• Georgia
  • Tbilisi, Georgia, 0102
    • Aleksandre Aladashvili Clinic LLC
• Israel
  • Jerusalem, Israel, 91120
    • Hadassah Ein Kerem University Medical Center
  • Lower Galilee
    • Tiberias, Lower Galilee, Israel, 15208
      • The Baruch Pade Medical Center
• Italy
  • Brescia, Italy
    • Spedali Civilia di Brescia
• Lebanon
  • Beirut, Lebanon, 1107-2020
    • American University of Beirut Medical Center
• Netherlands
  • Hoorn, Netherlands
    • Vasculair Onderzoek Centrum
• Poland
  • Wroclaw, Poland, 50-891
    • Clinical Military Hospital
• Romania
  • Bucharest, Romania, 014461
    • Emergency Clinical Hospital
• Singapore
  • Singapore, Singapore, 169609
    • National Heart Centre of Singapore Pte
• Spain
  • Murcia, Spain, 30001
    • University of Murcia
• Sweden
  • Malmö, Sweden, SE 20502
    • Skåne University Hospital
• Ukraine
  • Kyiv, Ukraine, 02000
    • The M.D. Strazhesko Institute of Cardiology
• United Kingdom
  • London, United Kingdom
    • Kings College Hospital NHS Foundation

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Currently hospitalised for an episode of acute heart failure (AHF) where AHF was the primary reason for hospitalisation. All of the following (i.e., items a to d) must apply:

   1. Upon admission for the AHF episode, persistent dyspnoea at rest in a recumbent sitting position (30-45°) or with minimal exertion
   2. Upon or during the AHF admission, at least 2 of the following clinical findings were present: i. Congestion on chest X-ray ii. Rales on chest auscultation iii. Oedema ≥1+ on a 0-3+ scale, indicating indentation of skin with mild digital pressure that requires 10 or more seconds to resolve in any dependent area including extremities or sacral region iv. Elevated jugular venous pressure (≥8 cm H2O)
   3. Natriuretic peptide levels, measured ≤72 hours of the AHF admission must have been: i. Brain natriuretic peptide (BNP) ≥400 pg/mL or N-terminal-pro-brain natriuretic peptide (NT-proBNP) ≥1,600 pg/mL or ii. BNP ≥600 pg/mL or NT-proBNP ≥2,400 pg/mL for subjects presenting with atrial fibrillation when the blood sample was taken iii. For subjects treated with an angiotensin receptor neprilysin inhibitor (ARNI) in the previous 4 weeks prior to randomisation only NT-proBNP values should be considered
   4. AHF episode treated with minimally 40 mg of IV furosemide (or equivalent IV loop diuretic defined as 20 mg of torasemide or 1 mg of bumetanide)
2. Subject is iron deficient defined as serum ferritin <100 ng/mL or 100 ng/mL ≤ serum ferritin ≤299 ng/mL if TSAT <20%.
3. Left ventricular ejection fraction <50% (assessed and documented within 12 months prior to randomisation).
4. Male or female aged ≥18 years old.
5. Subject (or legally acceptable representative)* has provided the appropriate written informed consent. Subject must provide written informed consent before any study-specific procedures are performed.

Exclusion Criteria:

1. Dyspnoea due to non-cardiac causes such as acute or chronic respiratory disorders or infections (i.e., severe chronic obstructive pulmonary disease, acute bronchitis, pneumonia, primary pulmonary hypertension).
2. Temperature >38°C (oral or equivalent), active infective endocarditis, sepsis, systemic inflammatory response syndrome, or any other active infection requiring anti-microbial treatment at any time during an Index hospitalisation. (Note that it does NOT include short-term prophylactic administration of antibiotics or short-term temperature elevation at admission which is no longer present at the time point of discharge/randomisation).
3. Documented restricted amyloid myocardiopathy, or acute myocarditis or hypertrophic obstructive, restrictive, or constrictive cardiomyopathy. (Note that it does NOT include restrictive mitral filling patterns seen on Doppler echocardiographic assessments of diastolic function).
4. Clinical evidence of acute coronary syndrome, transient ischemic attack or stroke, within the last 30 days prior randomisation.
5. Severe valvular or left ventricular outflow obstruction disease needing intervention.
6. Coronary-artery bypass graft, cardiac resynchronisation therapy device implantation, percutaneous intervention (e.g., cardiac, cerebrovascular, aortic, diagnostic catheters are allowed) or major surgery that led to significant blood loss, including thoracic and cardiac surgery, within the last 3 months prior to randomisation.
7. Subject has a body weight <35 kg at randomisation.
8. Subject at an immediate need of transfusion or with a Hb <8 g/dL* or with a Hb >15 g/dL.
9. Subjects on treatment for Vitamin B12 and/or serum folate deficiency. Note: Use of Vitamin B12 and folic acid as supplement therapy (not for deficiency treatment) is permitted.
10. Subject with a known anaemia not attributed to ID (e.g., other microcytic anaemia) or with an evidence of iron overload (e.g., haemochromatosis) or disturbances in the utilisation of iron.
11. Subject has known hypersensitivity to any of the study products to be administered or known serious hypersensitivity to other parenteral iron products.
12. Subject with known severe allergies including drug allergies, history of severe asthma, eczema or other atopic allergy and in subjects with immune or inflammatory conditions (e.g., systemic lupus erythematosus, rheumatoid arthritis).
13. History of erythropoietin stimulating agent, IV iron therapy, and/or blood transfusion in previous 3 months prior to randomisation.
14. Oral iron therapy at doses >100 mg/day in previous 4 weeks prior to randomisation. Note: Ongoing use of multivitamins containing iron <75 mg/day are permitted.
15. Currently receiving systemic chemotherapy and/or radiotherapy.
16. Renal dialysis (previous, current or planned within the next 6 months).
17. Subject has known active malignancy of any organ system, i.e., clinical evidence of current malignancy or not in stable remission for at least 3 years since completion of last treatment with exception of non-invasive basal cell carcinoma, squamous cell carcinoma of the skin or cervical intra-epithelial neoplasia.
18. Terminal illness other than HF with expected survival <12 months.
19. Chronic liver disease (including active hepatitis) and/or alanine transaminase or aspartate transaminase above 3 times the upper limit of the normal range.
20. Subjects with known hepatitis B surface antigen positivity and/or hepatitis C virus ribonucleic acid positivity.
21. Subject previously randomised into this study. Note: Subjects may be rescreened but when rescreened, all tests must fall inside the maximum specified screening windows for each criterion.
22. Subject is currently enrolled in or has completed any other investigational device or drug study <30 days prior to screening, or is receiving other investigational agent(s).
23. Subject is pregnant (e.g., positive human chorionic gonadotropin test) or breast feeding.
24. If of childbearing potential, subject is not using adequate contraceptive precautions. Subject must agree to use adequate contraception during the study and for 1 month after the last dose of study treatment. A highly effective method of birth control must be used.
25. Subject has a history of drug or alcohol abuse within 2 years prior to screening.

26. Subject has a significant medical condition(s), anticipated need for major surgery during the study, or any other kind of disorder that may be associated with increased risk to the subject, or may interfere with study assessments, outcomes, or the ability to provide written informed consent or comply with study procedures, in the Investigator's opinion.

    • Following section in italics is applicable for The Netherlands, Spain and Singapore only (NL, ES and SG only): 'The lower threshold of Hb values is set to 10 g/dL.'

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: TRIPLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
ACTIVE_COMPARATOR: ferric carboxymaltose; The first dose of study treatment will be administered for all randomised subjects while the patient is still hospitalised for the Index hospitalisation. The subsequent administrations of study treatment will be done as part of the outpatient clinic visits.	Drug: ferric carboxymaltose; FCM will be administered as an undiluted bolus injection. The study treatment dose (mL) to be administered will be determined by the patient's body weight and haemoglobin (Hb) value at the respective visits where study treatment will be administered; Other Names: Ferinject; Injectafer; Renegy; Iroprem
PLACEBO_COMPARATOR: normal saline 0.9%; The first dose of study treatment will be administered for all randomised subjects on the same day as randomisation.	Other: Normal saline 0.9%; Normal saline will be administered as a bolus injection.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
HF Hospitalizations and CV Death	HF = Heart Failure, CV = Cardiovascular. The composite of recurrent HF hospitalizations and CV death up to 52 weeks after randomization Total hospitalisations included first and recurrent events. If a participant was hospitalised for heart failure and died within 24 h from any cardiovascular event, this was counted as one event.	up to 52 weeks after randomization

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Recurrent CV Hospitalisations and CV Death	CV = Cardiovascular The composite of recurrent CV hospitalisations and CV death at 52 weeks after randomisation Total hospitalisations included first and recurrent events. If a participant was hospitalised for a cardiovascular reason and died within 24 h of admission from any cardiovascular event, this was counted as one event.	up to 52 weeks after randomization
HF Hospitalisations	HF = Heart Failure HF hospitalisations up to 52 weeks after randomisation analysed as recurrent event.	up to 52 weeks after randomisation
CV Mortality	CV = Cardiovascular CV mortality analysed as time to first event at 52 weeks after randomisation.	at 52 weeks after randomisation.
Composite of HF Hospitalisations or CV Death	HF = Heart Failure, CV = Cardiovascular Analysed as time to first event at 52 weeks after randomisation. The number of participants with at least one HF Hospitalisation or CV Death is presented below.	at 52 weeks after randomisation
Days Lost Due to HF Hospitalisation or CV Death	HF = Heart Failure, CV = Cardiovascular Number of days lost due to heart failure hospitalisations or cardiovascular death corresponds to the total number of days in hospital for heart failure from randomisation to last known date. Days lost due to cardiovascular death are added to the number of days lost due to heart failure hospitalisation.	at 52 weeks after randomisation

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
HF Hospitalisations	HF = Heart Failure Number of participants with at least one HF Hospitalisation up to 52 weeks after randomisation	up to 52 weeks after randomisation
CV Hospitalisations	CV = Cardiovascular Number of participants with at least one CV Hospitalisation up to 52 weeks after randomisation	up to 52 weeks after randomisation
All-cause Mortality	Number of participants who died up to 52 weeks after randomisation	up to 52 weeks after randomisation
Change From Baseline in NYHA Functional Class	NYHA = New York Heart Association NYHA functional class was assessed as Class I, II, III, IV or V: Class I - No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc. Class II - Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity. Class III - Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20-100 m). Comfortable only at rest. Class IV - Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients. If a participant was hospitalised at any point during any post-baseline visit and did not have any NYHA assessment for this visit, then Class IV was to be imputed for the visit. Class V - Imputed for participants who died. Lower response categories are better for score NYHA.	at 6, 12, 24 and 52 weeks after randomisation
Change From Baseline in the EQ-5D-5L Questionnaire Indexed Value	EQ-5D-5L: European Quality of Life-5 Dimensions-5 Levels The EQ 5D questionnaire consists of a health descriptive system for participants to self-classify and rate their health status on the day of administration. The descriptive system includes 5 items/dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression, which are coded from 1 (best state) to 5 (worst state).	at 6, 24 and 52 weeks after randomisation
KCCQ-12 Repeated-Measures Model for Analysis of Treatment Difference	KCCQ = Kansas City Cardiomyopathy Questionnaire The KCCQ 12 is a health-related quality of life questionnaire for Heart Failure. It is a 12 item questionnaire that quantifies physical function, symptoms (frequency, severity and recent change), social function, self-efficacy and knowledge and Quality of life. Scores are generated for each domain and scaled from 0 to 100, with 0 denoting the lowest reportable health status and 100 the highest reportable health status.	up to 52 weeks after randomisation

Collaborators and Investigators

• Sponsor: Vifor (International) Inc.
• Collaborators: Worldwide Clinical Trials; Cytel Inc.
• Investigators: Principal Investigator: Piotr Ponikowski, MD, Medical University Clinical Military Hospital

Publications and helpful links

General Publications

• Ponikowski P, Kirwan BA, Anker SD, McDonagh T, Dorobantu M, Drozdz J, Fabien V, Filippatos G, Gohring UM, Keren A, Khintibidze I, Kragten H, Martinez FA, Metra M, Milicic D, Nicolau JC, Ohlsson M, Parkhomenko A, Pascual-Figal DA, Ruschitzka F, Sim D, Skouri H, van der Meer P, Lewis BS, Comin-Colet J, von Haehling S, Cohen-Solal A, Danchin N, Doehner W, Dargie HJ, Motro M, Butler J, Friede T, Jensen KH, Pocock S, Jankowska EA; AFFIRM-AHF investigators. Ferric carboxymaltose for iron deficiency at discharge after acute heart failure: a multicentre, double-blind, randomised, controlled trial. Lancet. 2020 Dec 12;396(10266):1895-1904. doi: 10.1016/S0140-6736(20)32339-4. Epub 2020 Nov 13. Erratum In: Lancet. 2021 Nov 27;398(10315):1964.
• Ponikowski P, Kirwan BA, Anker SD, Dorobantu M, Drozdz J, Fabien V, Filippatos G, Haboubi T, Keren A, Khintibidze I, Kragten H, Martinez FA, McDonagh T, Metra M, Milicic D, Nicolau JC, Ohlsson M, Parhomenko A, Pascual-Figal DA, Ruschitzka F, Sim D, Skouri H, van der Meer P, Jankowska EA. Rationale and design of the AFFIRM-AHF trial: a randomised, double-blind, placebo-controlled trial comparing the effect of intravenous ferric carboxymaltose on hospitalisations and mortality in iron-deficient patients admitted for acute heart failure. Eur J Heart Fail. 2019 Dec;21(12):1651-1658. doi: 10.1002/ejhf.1710. Epub 2019 Dec 28.

Study record dates

Study Major Dates

• Study Start (ACTUAL): April 3, 2017
• Primary Completion (ACTUAL): July 21, 2020
• Study Completion (ACTUAL): July 21, 2020

Study Registration Dates

• First Submitted: October 14, 2016
• First Submitted That Met QC Criteria: October 14, 2016
• First Posted (ESTIMATE): October 18, 2016

Study Record Updates

• Last Update Posted (ACTUAL): June 18, 2021
• Last Update Submitted That Met QC Criteria: May 25, 2021
• Last Verified: May 1, 2021

More Information

Terms related to this study

• Keywords: Acute Heart Failure; Iron Deficiency
• Additional Relevant MeSH Terms: Heart Diseases; Cardiovascular Diseases; Metabolic Diseases; Hematologic Diseases; Anemia, Hypochromic; Anemia; Iron Metabolism Disorders; Heart Failure; Anemia, Iron-Deficiency
• Other Study ID Numbers: FER-CARS-06; 2016-001467-36 (EUDRACT_NUMBER)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No