Dietary Prevention of Heart Failure in Hypertensive Metabolic Syndrome

Tens of thousands of Veterans have heart failure with preserved ejection fraction (HFpEF), and suffer poor quality of life, frequent hospitalizations, and high death rates. Older Veterans and those with high blood pressure, obesity, and the metabolic syndrome (abnormal cholesterol and resistance to insulin's effects) are particularly at risk for HFpEF. However, it is not clear why only some Veterans in this risk group eventually develop HFpEF. Extensive information from experimental animal models and some human studies suggests that dietary patterns in vulnerable 'salt-sensitive' people could contribute to the risk for HFpEF. Reducing salt intake and increasing overall dietary quality in at-risk Veterans could prevent heart and blood vessel damage that ultimately leads to HFpEF. Reducing the development of HFpEF, which currently has no definitive treatment, is highly relevant to the VA's mission to emphasize prevention of disease and population health.

Study Overview

• Status: Active, not recruiting
• Conditions: Heart Failure
• Intervention / Treatment: Behavioral: Performance of WHEELS-I in promoting DASH/SRD adoption; Behavioral: Effects of a 2-week DASH/SRD intervention vs. control diet on HFpEF functional cardiovascular risk factors

Detailed Description

COVID-19 in-person visit hold has been removed- screening and actively enrolling. We are not currently performing sublingual darkfield microscopy because of the need for close face-to-face contact with an open-mouthed patient for several minutes in the setting of COVID-19 pandemic.

Patients with heart failure (HF) account for over 1,200,000 VA outpatient visits per year, and HF remains the most common cause for hospital admission in the VA. Approximately 1/3 of Veterans with HF have 'preserved' ejection fraction (HFpEF), or relatively normal contractile function of the heart; such patients suffer functional decline and poor quality of life, and half die within 5 years after diagnosis. Risk factors for developing HFpEF are more common in Veterans than the general population, and the burden of HFpEF to the VA system will rise in the years ahead as these Veterans age. Preventive efforts are critical, but are hampered by gaps in knowledge related to HFpEF pathophysiology. The long term goal of this proposal is to prevent the onset of HFpEF in at-risk Veterans. Hypertension (HTN) confers the highest population-attributable risk for HFpEF, particularly when accompanied by the metabolic syndrome, a constellation of obesity, insulin resistance, and dyslipidemia. Animal models of HTN and metabolic syndrome develop HFpEF due to microvascular oxidative stress and inflammation induced by high sodium intake. Recent data from cardiac biopsies confirm similar mechanisms in human HFpEF. Dietary sodium restriction is widely recommended to prevent HTN-associated heart disease in humans, but this advice is now controversial. Few studies have examined how individual differences in response to sodium intake affect risk. "Salt-sensitive" persons have blood pressure (BP) that changes in parallel with sodium intake, and commonly develop cardiovascular abnormalities associated with HFpEF. The overall objective of this proposal is to evaluate salt-sensitivity as a novel, diet-responsive risk factor for incident HFpEF in Veterans with HTN and metabolic syndrome. The central hypothesis is that the sodium-restricted Dietary Approaches to Stop Hypertension (DASH/SRD) eating pattern will improve cardiovascular functional and structural risk factors for HFpEF in Veterans with the salt-sensitive phenotype. Guided by findings in experimental models, cohort studies, and strong preliminary evidence from the investigators' research group, this hypothesis will be tested in a two-phase study and by pursuing three specific aims: 1) Determine effects of DASH/SRD on functional and structural cardiovascular HFpEF risk factors in salt-sensitive vs. salt-resistant Veterans, 2) measure the effect of an electronically-delivered tailored-messaging intervention on DASH/SRD adherence, and 3) determine effects of DASH/SRD intervention and adoption on microvascular function and assess the endothelial glycocalyx as a biomarker of cardiovascular response to DASH/SRD. Phase 1 of the study is a crossover-randomized comparison of DASH/SRD vs. control diet for two weeks each, and Phase 2 a 6-month extension to promote DASH/SRD adherence. The salt-sensitive phenotype will be defined by between-diet changes in 24-hour mean BP during Phase 1. In Phase 2, the efficacy of motivational interviewing-based counseling and the Women's and Men's Hypertension Experiences and Emerging Lifestyles Intervention (WHEELS-I), a tailored messaging program, to sustain DASH/SRD adherence, will be compared. Echocardiography and arterial tonometry will be used to assess HFpEF-related cardiovascular parameters during short- and longer-term dietary modification and their interaction with salt-sensitivity. In vivo microscopy and novel blood testing will assess microvascular function and the integrity of the endothelial glycocalyx, a blood vessel lining that is sodium-responsive and may mediate the adverse effects of salt-sensitivity. This proposal is innovative because it represents the first study to examine salt-sensitivity as a factor promoting HFpEF in Veterans with HTN and metabolic syndrome, the highest risk group for incident HFpEF. Moreover, it aims to link microvascular dysfunction, an important pathway in human HFpEF, with endothelial glycocalyx damage, a potential biomarker for sodium-mediated vascular risk. The proposed research is significant because it will vertically advance the investigators' understanding of how dietary factors contribute to the pathophysiology of HFpEF, a major and growing health threat to Veterans.

• Study Type: Interventional
• Enrollment (Actual): 81
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Lauren E Herty, MPH RD; Phone Number: (734) 222-7490; Email: Lauren.Herty@va.gov
• Study Contact Backup: Name: Scott L Hummel, MD; Email: Scott.Hummel@va.gov

Study Locations

• United States
  • Michigan
    • Ann Arbor, Michigan, United States, 48105-2303
      • VA Ann Arbor Healthcare System, Ann Arbor, MI

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 45 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Veterans aged 45 years with HTN

  • here defined as screening systolic BP 130 and/or diastolic BP 85 mmHg, or current use of anti-hypertensive drugs

• and metabolic syndrome

  • body mass index 30 kg/m2 and/or waist circumference >94 cm
• Participants must also be willing to participate in the WHEELS-I program by using a smartphone application or email

Exclusion Criteria:

• On-treatment systolic BP of >160 mmHg at screening visit
• previous history of HF
• left ventricular ejection fraction <50%
• moderate or severe valvular heart disease
• myocardial infarction or stroke within the prior 6 months
• chronic kidney disease with estimated glomerular filtration rate <45 ml/min/ 1.73m2
• unoperated aortic aneurysm for which surgery is indicated, prior hyperkalemia requiring urgent treatment
• hemoglobin <9 gm/dL

• investigator-determined factors: severe pulmonary disease, e.g.:

  • oxygen-requiring

• hepatic disease, e.g.:

  • cirrhosis
• severely uncontrolled diabetes (hemoglobin A1c >10%)
• active cancer other than non-melanoma skin or low-risk prostate cancer
• other comorbidity with expected survival <12 months
• active alcohol/illicit substance abuse
• and/or a history of persistent nonadherence to treatment
• Veterans involved in another study (unless it is survey-only and the other investigator will allow us to invite the person in a survey-only study to consider our study)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Sequential Assignment
• Masking: Double

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Motivational Interviewing + WHEELS-I; In addition to motivational interviewing-based counseling with a registered dietitian to promote adoption of the sodium-restricted Dietary Approaches to Stop Hypertension (DASH/SRD) eating plan., participants in this arm will also receive an electronically-delivered tailored messaging intervention called Women's and Men's Hypertension Experiences and Emerging Lifestyle Intervention (WHEELS-I).	Behavioral: Performance of WHEELS-I in promoting DASH/SRD adoption; Participants will receive the WHEELS-I electronically-delivered tailored messaging intervention in addition to motivational interviewing-based counseling.; Other Names: Phase 2
Active Comparator: Motivational Interviewing; Participants in this arm will receive motivational interviewing-based counseling with a registered dietitian to promote adoption of the sodium-restricted Dietary Approaches to Stop Hypertension (DASH/SRD) eating plan.	Behavioral: Performance of WHEELS-I in promoting DASH/SRD adoption; Participants will receive the WHEELS-I electronically-delivered tailored messaging intervention in addition to motivational interviewing-based counseling.; Other Names: Phase 2
Experimental: DASH/SRD Diet; Participants in this arm will receive prepared, pre-packaged meals containing 1150mg of sodium.	Behavioral: Effects of a 2-week DASH/SRD intervention vs. control diet on HFpEF functional cardiovascular risk factors; Participants will be randomized to the sequence DASH/SRD-control diet or control diet-DASH/SRD, and consume the diets for 14 days each.; Other Names: Phase 1
Placebo Comparator: Control Diet; Participants in this arm will receive prepared, pre-packaged meals containing 5750mg of sodium.	Behavioral: Effects of a 2-week DASH/SRD intervention vs. control diet on HFpEF functional cardiovascular risk factors; Participants will be randomized to the sequence DASH/SRD-control diet or control diet-DASH/SRD, and consume the diets for 14 days each.; Other Names: Phase 1

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Carotid-femoral pulse wave velocity	Velocity of pulse wave traveling between carotid and femoral artery; validated measure of arterial stiffness	Phase 1 of study, change from baseline at the end of week 2 and week 4
Left ventricular mass index	Left ventricular mass indexed to height	Phase 2 of study, change from baseline to 6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Ventricular stiffness	Ventricular stiffness k, by Parametrized Diastolic Formalism analysis	Phase 1 of study, change from baseline at the end of week 2 and week 4
Global longitudinal left ventricular strain	Global longitudinal left ventricular strain, a sensitive measure of ventricular systolic function	Phase 1 of study, change from baseline at the end of week 2 and week 4
Global left atrial strain	Global left atrial strain, a novel measure of atrial function	Phase 1 of study, change from baseline at the end of week 2 and week 4
Carotid-femoral pulse wave velocity	Velocity of pulse wave traveling between carotid and femoral artery; validated measure of arterial stiffness	Phase 2 of study, change from baseline to 6 months
Left atrial volume	Left atrial volume by 3D echocardiography	Phase 2 of study, change from baseline to 6 months

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Salt-sensitivity phenotype	Change in 24-hour mean of >= 8 mmHg will define the salt-sensitive blood pressure phenotype	Phase 1 of study, change from baseline at the end of week 2 and week 4
24-hour urinary sodium excretion	Measure of dietary sodium intake	Phase 2 of study, change from baseline to 6 months
Sodium-restricted DASH diet adherence	Sodium-restricted DASH diet score on Food Frequency Questionnaire, measured by complete or partial adherence to 9 dietary domains	Phase 2 of study, change from baseline to 6 months
Sodium-restricted DASH diet adherence	Analysis of 3-day food diaries by a Registered Dietitian, utilizing the Nutrition Data System for Research	Phase 2 of study, months 1 and 6

Collaborators and Investigators

• Sponsor: VA Office of Research and Development
• Investigators: Principal Investigator: Scott L. Hummel, MD, VA Ann Arbor Healthcare System, Ann Arbor, MI

Study record dates

Study Major Dates

• Study Start (Actual): January 2, 2019
• Primary Completion (Estimated): March 31, 2024
• Study Completion (Estimated): June 30, 2024

Study Registration Dates

• First Submitted: May 26, 2017
• First Submitted That Met QC Criteria: May 26, 2017
• First Posted (Actual): May 31, 2017

Study Record Updates

• Last Update Posted (Estimated): January 19, 2024
• Last Update Submitted That Met QC Criteria: January 17, 2024
• Last Verified: January 1, 2024

More Information

Terms related to this study

• Keywords: obesity; hypertension; diastolic function; sodium; vascular stiffness; DASH diet
• Additional Relevant MeSH Terms: Heart Diseases; Cardiovascular Diseases; Glucose Metabolism Disorders; Metabolic Diseases; Insulin Resistance; Hyperinsulinism; Heart Failure; Metabolic Syndrome
• Other Study ID Numbers: CARA-009-16F; 9050 (Other Grant/Funding Number: VA CSR&D Merit)

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
• product manufactured in and exported from the U.S.: No