Cardiovascular Effects of Parathyroid Hormone Analogues in Chronic Hypoparathyroidism (PaTH CV)

Effect of Long-acting PTH Analogues on Markers of Subclinical Arterial and Myocardial Injury in Chronic Hypoparathyroidism..

The goal of this study is to evaluate cardiovascular effects of long-acting parathyroid hormone (PTH) analogues in adults with chronic hypoparathyroidism. The main questions it aims to answer are:

• Do patients with hypoparathyroidism have increased arterial stiffness and markers of subclinical cardiovascular injury compared to healthy individuals?
• Does treatment with a long-acting PTH analogue improve vascular and cardiac function over time compared to conventional therapy? This is a multi-center study with two parts: a cross-sectional comparison and a 12-month prospective follow-up. Adults with chronic hypoparathyroidism and matched healthy controls will undergo clinical evaluation, vascular measurements, cardiac imaging, and blood tests.

In the prospective part, patients that just started long-acting PTH analogue therapy based on their treating physicians choice will be followed for 12 months, with repeat assessments at baseline, 3 months, and 12 months to evaluate changes in cardiovascular markers.

Study Overview

• Status: Active, not recruiting
• Conditions: Chronic Hypoparathyroidism
• Intervention / Treatment: Diagnostic test: Arterial stiffness in the aorta by measurement of pulse wave velocity; Diagnostic test: Central blood pressures and reflected waves in the aorta; Diagnostic test: Carotid and femoral intima-media thickness (IMT) and number of carotid or femoral plaques; Diagnostic test: Imaging of the sublingual microcirculation (GlycoCheck system); Diagnostic test: Ankle-brachial index (ABI); Diagnostic test: Fundoscopy; Diagnostic test: Cardiac Ultrasonography Study; Diagnostic test: Local shear stress in brachial and carotid artery; Diagnostic test: Peripheral and aortic office and ambulatory blood pressure; Diagnostic test: Circulating levels of myocardial biomarkers; Diagnostic test: Evaluation of Calcium metabolism

Detailed Description

The goal of this study is to better understand how chronic hypoparathyroidism affects heart and blood vessel health, and whether treatment with a long-acting parathyroid hormone (PTH) analogue can improve cardiovascular function. Hypoparathyroidism is a rare condition in which the body does not produce enough PTH, leading to low calcium levels and possible long-term complications, including an increased risk of cardiovascular disease.

This study aims to answer the following main questions:

Do people with chronic hypoparathyroidism have early (subclinical) signs of damage to the heart and blood vessels compared to people without the condition? Does treatment with a long-acting PTH analogue improve vascular health and reduce early markers of cardiovascular disease over time?

The study includes two parts. In the first part, researchers will compare adults with hypoparathyroidism-either receiving standard treatment (calcium and vitamin D) or long-acting PTH therapy-with healthy individuals of similar age and health characteristics. Participants that will undergo the non-invasive tests to assess blood vessel stiffness, blood pressure, microcirculation, and heart function, along with blood tests to measure calcium balance and cardiovascular biomarkers, as part of routine clinical practice will be eligible for the study.

In the second part, participants with hypoparathyroidism who are starting treatment with a long-acting PTH analogue will be followed for 12 months. They will be evaluated at the beginning of the study, at 3 months and again at 12 months. Researchers will track changes in blood vessel function, heart performance, and biochemical markers to determine whether restoring normal PTH levels improves cardiovascular health.

All participants will undergo detailed clinical assessments, including imaging of blood vessels and the heart, as well as laboratory testing. The findings from this study may help improve understanding of cardiovascular risk in hypoparathyroidism and guide future treatment strategies.

• Study Type: Observational
• Enrollment (Estimated): 210

Contacts and Locations

Study Locations

• Greece
  • Athens, Greece, 11527
    • Alexandra General Hospital of Athens
  • Athens, Greece, 11527
    • Medical School, National and Kapodistrian University of Athens, LAIKO General Hospital of Athens

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

• Sampling Method: Non-Probability Sample

Study Population

Adults (≥18y) with chronic HypoPT (≥12 months) currently treated with conventional therapy or palopegteriparatide for more than one year and comparable healthy individuals, matched to patients based on key characteristics such as age, sex, and cardiovascular risk factors

Description

Inclusion Criteria:

- Cross sectional arm: Baseline State: Adults (≥18y) with chronic HypoPT (≥12 months) currently treated with conventional therapy or palopegteriparatide for more than one year

-Prospective Follow-up: Adults (≥18y) with chronic HypoPT (≥12 months) currently treated with conventional therapy and about to start treatment with palopegteriparatide willing to undergo baseline measurements (prior to the first dose) and repeat measurements at 3 and 12 months.

Exclusion Criteria:

• Renal Function: CKD Stage 3 or higher (eGFR < 60 mL/min/1.73 m²)

• Uncontrolled Risk Factors:

  • SBP > 180/100 mmHg
  • Uncontrolled endocrine diseases (e.g., hyper- or hypothyroidism, diabetes mellitus type 2 with HbA1c>7.5%).
• Bone Health: Any metabolic bone disease other than hypoparathyroidism (excluding osteoporosis)
• Documented Atrial Fibrillation (ECG)
• Contraindication to long acting PTH analogue as per product labeling

Study Plan

How is the study designed?

Number of groups / cohorts

4

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Patients with chronic hypoparathyroidism under conventional treatment (disease control); 20-30 Hypo-PT patients aged ≥18 on conventional HypoPT therapy with any dose of activated vitamin D and calcium and native vitamin D supplements for at least 12 months	Diagnostic test: Arterial stiffness in the aorta by measurement of pulse wave velocity; Carotid-femoral pulse wave velocity (c-f PWV) is an established index of aortic stiffness and an independent predictor of worse cardiovascular prognosisIt is considered as the gold standard for assessing aortic stiffness non-invasively and is calculated from measurements of pulse transit time and the distance travelled between 2 recording sites with a validated non-invasive device (Complior, Artech Medical, France). Two different pulse waves are obtained at the same time transcutaneously with the patient in a supine position at 2 sites, at the right common carotid artery and the right femoral artery (i.e. 'carotid-femoral' PWV) by using pressure-sensitive transducers.; Diagnostic test: Central blood pressures and reflected waves in the aorta; Non-invasive estimation of aortic pressure waveforms and reflected waves by pulse wave analysis (PWA) will be performed in the Angiology laboratory by the SphygmoCor System (AtCor Medical Pty Ltd, Sydney, Australia). The radial artery is gently and steadily compressed against the underlying bone, thus flattening it and equalizing circumferential pressures, allowing radial pressure waves to be recorded by a high fidelity micromanometer placed on the tip of a hand - held tonometer the size of a pen (Millar). Optimal recording is obtained if the wrist is bent outward and supported by using a small cushion or the operator's hand. The following indices are measured: augmentation index (AI, percentage) normalized for the heart rate of 75 bpm, expressed as a percentage of the aortic pulse pressure,; central systolic and diastolic pressures (cBP),; time to the beginning of the reflected wave (in milliseconds) and; blood pressure amplification calculated as the ratio of peripheral; Diagnostic test: Carotid and femoral intima-media thickness (IMT) and number of carotid or femoral plaques; B-mode ultrasound examination will also be performed, using a 14.0 MHz multi-frequency linear array probe attached to a high-resolution ultrasound machine (Vivid 7 Pro, GE Healthcare, USA). All scans are going to be performed by the same operator. Carotid intima-media thickness (ccIMT) will be measured at the distal 1.0 cm of the common carotid proximal to the bifurcation as previously described (23) . In each segment 3 measurements of the maximal IMT in the far wall will be averaged, after excluding plaque thickness. The average of the maximal IMT will be used in the analyses. Femoral IMT (fIMT) will be measured on each side, scanning a 1cm-long arterial segment proximal to the femoral bifurcation, defined as the common femoral artery segment and the average value of IMT of the far wall will be estimated. A cutoff value of >0.9 mm for mean ccIMT or fIMT will be considered increased. Plaques to carotid and femoral arteries are defined as a focal structure that protrudes into the arteri; Diagnostic test: Imaging of the sublingual microcirculation (GlycoCheck system); The measurement procedure and the calculation of the sublingual microvascular parameters is performed as follows: the probe of a hand-held side-stream darkfield (SDF) videomicroscope (CapiScope HVCS, KK Technology, Honiton, UK) is placed on the sublingual mucosa of the subject, to obtain video recordings of the sublingual microvasculature. Subsequently, an analysis software (the GlycoCheck Measurement System Software Version 5.3.3) selects and analyses SDF images that are of sufficient quality (adequate focus, adequate contrast and limited movement) and automatically calculates the sublingual microcirculation parameters, such as vascular density (VD), red blood cell filling (RBCF), and perfused boundary region (PBR).; Diagnostic test: Ankle-brachial index (ABI); The primary non-invasive test for the diagnosis of lower extremity artery disease (LEAD) is the ABI. A cut-off value of <0.9 will be used for the diagnosis of LEAD and as predictive index of atherosclerosis, associated with increased risk of cardiovascular morbidity and mortality. Also, a cut-off value of >1.40 will be used as an index of stiffened arteries, also associated with increased mortality. For its measurement, a 10-12 cm sphygmomanometer cuff will be placed just above the ankle and a (handheld) Doppler instrument (5-10 MHz) will measure the pressure of the posterior and anterior tibial arteries of each foot. The highest ankle systolic pressure will be divided by the highest brachial systolic pressure, resulting in an ABI per leg.; Diagnostic test: Fundoscopy; A set of colour and black-and-white fundus images photograph per eye will be taken by well-trained ophthalmic photographers: macula-centered images using the handheld Optomed Aurora fundus cameras without pupil dilation. The images obtained with the handheld fundus camera had a field of view of 50° and 5 mega-pixel resolution; Diagnostic test: Cardiac Ultrasonography Study; Participants will undergo a baseline echocardiographic examination. Standard protocol will be used and standard measurements from 2-D and Doppler echocardiography will be made. LV end-diastolic and end-systolic volumes, as well as ejection fraction, will be derived from the apical 4- and 2-chamber views using the biplane Simpson's rule. Left ventricular mass will be calculated according to Devereux's formula. Doppler examination will include interrogation of mitral inflow, and early (E) and late (A) peak diastolic velocities and deceleration time will be measured. Tissue Doppler analysis will include pulse wave interrogation of the medial and lateral mitral annulus, peak diastolic early E΄ annular velocities will be obtained and the mean value and E/E' will be calculated. In addition, Speckle-tracking analysis will be applied to estimate LV rotational mechanics, and longitudinal strain parameters. Parasternal short-axis views at the level of the mitral valve and apex, and standard apic; Diagnostic test: Local shear stress in brachial and carotid artery; In order to calculate local shear stress in brachial and carotid artery, measurements of mean flow velocity in the lumen of these arteries will be needed. These measurements will be obtained, while performing carotid ultrasonography and FMD in brachial artery, as previously described. In detail, the form to calculate shear stress is: shear stress (in dyn/cm2 ) = 8×μ× mean flow velocity/resting diameter, where μ is the viscosity of blood which was assumed to be 0.035 dyne s/cm2; Diagnostic test: Peripheral and aortic office and ambulatory blood pressure; The peripheral and aortic office blood pressure will be assessed using specialized equipment (certified blood pressure monitor). 24-hour Ambulatory Blood pressure monitoring for measurement of 24 hour peripheral and aortic; Diagnostic test: Circulating levels of myocardial biomarkers; Fasting venous blood samples will be collected for evaluation of myocardial biomarkers (hs-troponin I, NT-proBNP). Additional samples will be obtained for isolation of PBMCs.; Diagnostic test: Evaluation of Calcium metabolism; Fasting venous blood samples will be collected for evaluation of calcium metabolism (PTH, calcium, albumin, magnesium, phosphate, 25-hydroxyvitamin D) .
Patients with chronic hypoparathyroidism under treatment with palopegteriparatide; 40-50 Hypo-PT patients aged ≥18 treated with Palopegteriparatide (TransCon PTH) for at least 12 months	Diagnostic test: Arterial stiffness in the aorta by measurement of pulse wave velocity; Carotid-femoral pulse wave velocity (c-f PWV) is an established index of aortic stiffness and an independent predictor of worse cardiovascular prognosisIt is considered as the gold standard for assessing aortic stiffness non-invasively and is calculated from measurements of pulse transit time and the distance travelled between 2 recording sites with a validated non-invasive device (Complior, Artech Medical, France). Two different pulse waves are obtained at the same time transcutaneously with the patient in a supine position at 2 sites, at the right common carotid artery and the right femoral artery (i.e. 'carotid-femoral' PWV) by using pressure-sensitive transducers.; Diagnostic test: Central blood pressures and reflected waves in the aorta; Non-invasive estimation of aortic pressure waveforms and reflected waves by pulse wave analysis (PWA) will be performed in the Angiology laboratory by the SphygmoCor System (AtCor Medical Pty Ltd, Sydney, Australia). The radial artery is gently and steadily compressed against the underlying bone, thus flattening it and equalizing circumferential pressures, allowing radial pressure waves to be recorded by a high fidelity micromanometer placed on the tip of a hand - held tonometer the size of a pen (Millar). Optimal recording is obtained if the wrist is bent outward and supported by using a small cushion or the operator's hand. The following indices are measured: augmentation index (AI, percentage) normalized for the heart rate of 75 bpm, expressed as a percentage of the aortic pulse pressure,; central systolic and diastolic pressures (cBP),; time to the beginning of the reflected wave (in milliseconds) and; blood pressure amplification calculated as the ratio of peripheral; Diagnostic test: Carotid and femoral intima-media thickness (IMT) and number of carotid or femoral plaques; B-mode ultrasound examination will also be performed, using a 14.0 MHz multi-frequency linear array probe attached to a high-resolution ultrasound machine (Vivid 7 Pro, GE Healthcare, USA). All scans are going to be performed by the same operator. Carotid intima-media thickness (ccIMT) will be measured at the distal 1.0 cm of the common carotid proximal to the bifurcation as previously described (23) . In each segment 3 measurements of the maximal IMT in the far wall will be averaged, after excluding plaque thickness. The average of the maximal IMT will be used in the analyses. Femoral IMT (fIMT) will be measured on each side, scanning a 1cm-long arterial segment proximal to the femoral bifurcation, defined as the common femoral artery segment and the average value of IMT of the far wall will be estimated. A cutoff value of >0.9 mm for mean ccIMT or fIMT will be considered increased. Plaques to carotid and femoral arteries are defined as a focal structure that protrudes into the arteri; Diagnostic test: Imaging of the sublingual microcirculation (GlycoCheck system); The measurement procedure and the calculation of the sublingual microvascular parameters is performed as follows: the probe of a hand-held side-stream darkfield (SDF) videomicroscope (CapiScope HVCS, KK Technology, Honiton, UK) is placed on the sublingual mucosa of the subject, to obtain video recordings of the sublingual microvasculature. Subsequently, an analysis software (the GlycoCheck Measurement System Software Version 5.3.3) selects and analyses SDF images that are of sufficient quality (adequate focus, adequate contrast and limited movement) and automatically calculates the sublingual microcirculation parameters, such as vascular density (VD), red blood cell filling (RBCF), and perfused boundary region (PBR).; Diagnostic test: Ankle-brachial index (ABI); The primary non-invasive test for the diagnosis of lower extremity artery disease (LEAD) is the ABI. A cut-off value of <0.9 will be used for the diagnosis of LEAD and as predictive index of atherosclerosis, associated with increased risk of cardiovascular morbidity and mortality. Also, a cut-off value of >1.40 will be used as an index of stiffened arteries, also associated with increased mortality. For its measurement, a 10-12 cm sphygmomanometer cuff will be placed just above the ankle and a (handheld) Doppler instrument (5-10 MHz) will measure the pressure of the posterior and anterior tibial arteries of each foot. The highest ankle systolic pressure will be divided by the highest brachial systolic pressure, resulting in an ABI per leg.; Diagnostic test: Fundoscopy; A set of colour and black-and-white fundus images photograph per eye will be taken by well-trained ophthalmic photographers: macula-centered images using the handheld Optomed Aurora fundus cameras without pupil dilation. The images obtained with the handheld fundus camera had a field of view of 50° and 5 mega-pixel resolution; Diagnostic test: Cardiac Ultrasonography Study; Participants will undergo a baseline echocardiographic examination. Standard protocol will be used and standard measurements from 2-D and Doppler echocardiography will be made. LV end-diastolic and end-systolic volumes, as well as ejection fraction, will be derived from the apical 4- and 2-chamber views using the biplane Simpson's rule. Left ventricular mass will be calculated according to Devereux's formula. Doppler examination will include interrogation of mitral inflow, and early (E) and late (A) peak diastolic velocities and deceleration time will be measured. Tissue Doppler analysis will include pulse wave interrogation of the medial and lateral mitral annulus, peak diastolic early E΄ annular velocities will be obtained and the mean value and E/E' will be calculated. In addition, Speckle-tracking analysis will be applied to estimate LV rotational mechanics, and longitudinal strain parameters. Parasternal short-axis views at the level of the mitral valve and apex, and standard apic; Diagnostic test: Local shear stress in brachial and carotid artery; In order to calculate local shear stress in brachial and carotid artery, measurements of mean flow velocity in the lumen of these arteries will be needed. These measurements will be obtained, while performing carotid ultrasonography and FMD in brachial artery, as previously described. In detail, the form to calculate shear stress is: shear stress (in dyn/cm2 ) = 8×μ× mean flow velocity/resting diameter, where μ is the viscosity of blood which was assumed to be 0.035 dyne s/cm2; Diagnostic test: Peripheral and aortic office and ambulatory blood pressure; The peripheral and aortic office blood pressure will be assessed using specialized equipment (certified blood pressure monitor). 24-hour Ambulatory Blood pressure monitoring for measurement of 24 hour peripheral and aortic; Diagnostic test: Circulating levels of myocardial biomarkers; Fasting venous blood samples will be collected for evaluation of myocardial biomarkers (hs-troponin I, NT-proBNP). Additional samples will be obtained for isolation of PBMCs.; Diagnostic test: Evaluation of Calcium metabolism; Fasting venous blood samples will be collected for evaluation of calcium metabolism (PTH, calcium, albumin, magnesium, phosphate, 25-hydroxyvitamin D) .
Healthy controls; Healthy controls: 170 Healthy controls matched with group 1 and group 2 for age, sex, CVD presence, propensity score, DM2, renal function, BMI and SBP, retrospectively recruited from the Athens Angiometabolic Cohort	Diagnostic test: Arterial stiffness in the aorta by measurement of pulse wave velocity; Carotid-femoral pulse wave velocity (c-f PWV) is an established index of aortic stiffness and an independent predictor of worse cardiovascular prognosisIt is considered as the gold standard for assessing aortic stiffness non-invasively and is calculated from measurements of pulse transit time and the distance travelled between 2 recording sites with a validated non-invasive device (Complior, Artech Medical, France). Two different pulse waves are obtained at the same time transcutaneously with the patient in a supine position at 2 sites, at the right common carotid artery and the right femoral artery (i.e. 'carotid-femoral' PWV) by using pressure-sensitive transducers.; Diagnostic test: Central blood pressures and reflected waves in the aorta; Non-invasive estimation of aortic pressure waveforms and reflected waves by pulse wave analysis (PWA) will be performed in the Angiology laboratory by the SphygmoCor System (AtCor Medical Pty Ltd, Sydney, Australia). The radial artery is gently and steadily compressed against the underlying bone, thus flattening it and equalizing circumferential pressures, allowing radial pressure waves to be recorded by a high fidelity micromanometer placed on the tip of a hand - held tonometer the size of a pen (Millar). Optimal recording is obtained if the wrist is bent outward and supported by using a small cushion or the operator's hand. The following indices are measured: augmentation index (AI, percentage) normalized for the heart rate of 75 bpm, expressed as a percentage of the aortic pulse pressure,; central systolic and diastolic pressures (cBP),; time to the beginning of the reflected wave (in milliseconds) and; blood pressure amplification calculated as the ratio of peripheral; Diagnostic test: Carotid and femoral intima-media thickness (IMT) and number of carotid or femoral plaques; B-mode ultrasound examination will also be performed, using a 14.0 MHz multi-frequency linear array probe attached to a high-resolution ultrasound machine (Vivid 7 Pro, GE Healthcare, USA). All scans are going to be performed by the same operator. Carotid intima-media thickness (ccIMT) will be measured at the distal 1.0 cm of the common carotid proximal to the bifurcation as previously described (23) . In each segment 3 measurements of the maximal IMT in the far wall will be averaged, after excluding plaque thickness. The average of the maximal IMT will be used in the analyses. Femoral IMT (fIMT) will be measured on each side, scanning a 1cm-long arterial segment proximal to the femoral bifurcation, defined as the common femoral artery segment and the average value of IMT of the far wall will be estimated. A cutoff value of >0.9 mm for mean ccIMT or fIMT will be considered increased. Plaques to carotid and femoral arteries are defined as a focal structure that protrudes into the arteri; Diagnostic test: Imaging of the sublingual microcirculation (GlycoCheck system); The measurement procedure and the calculation of the sublingual microvascular parameters is performed as follows: the probe of a hand-held side-stream darkfield (SDF) videomicroscope (CapiScope HVCS, KK Technology, Honiton, UK) is placed on the sublingual mucosa of the subject, to obtain video recordings of the sublingual microvasculature. Subsequently, an analysis software (the GlycoCheck Measurement System Software Version 5.3.3) selects and analyses SDF images that are of sufficient quality (adequate focus, adequate contrast and limited movement) and automatically calculates the sublingual microcirculation parameters, such as vascular density (VD), red blood cell filling (RBCF), and perfused boundary region (PBR).; Diagnostic test: Ankle-brachial index (ABI); The primary non-invasive test for the diagnosis of lower extremity artery disease (LEAD) is the ABI. A cut-off value of <0.9 will be used for the diagnosis of LEAD and as predictive index of atherosclerosis, associated with increased risk of cardiovascular morbidity and mortality. Also, a cut-off value of >1.40 will be used as an index of stiffened arteries, also associated with increased mortality. For its measurement, a 10-12 cm sphygmomanometer cuff will be placed just above the ankle and a (handheld) Doppler instrument (5-10 MHz) will measure the pressure of the posterior and anterior tibial arteries of each foot. The highest ankle systolic pressure will be divided by the highest brachial systolic pressure, resulting in an ABI per leg.; Diagnostic test: Fundoscopy; A set of colour and black-and-white fundus images photograph per eye will be taken by well-trained ophthalmic photographers: macula-centered images using the handheld Optomed Aurora fundus cameras without pupil dilation. The images obtained with the handheld fundus camera had a field of view of 50° and 5 mega-pixel resolution; Diagnostic test: Cardiac Ultrasonography Study; Participants will undergo a baseline echocardiographic examination. Standard protocol will be used and standard measurements from 2-D and Doppler echocardiography will be made. LV end-diastolic and end-systolic volumes, as well as ejection fraction, will be derived from the apical 4- and 2-chamber views using the biplane Simpson's rule. Left ventricular mass will be calculated according to Devereux's formula. Doppler examination will include interrogation of mitral inflow, and early (E) and late (A) peak diastolic velocities and deceleration time will be measured. Tissue Doppler analysis will include pulse wave interrogation of the medial and lateral mitral annulus, peak diastolic early E΄ annular velocities will be obtained and the mean value and E/E' will be calculated. In addition, Speckle-tracking analysis will be applied to estimate LV rotational mechanics, and longitudinal strain parameters. Parasternal short-axis views at the level of the mitral valve and apex, and standard apic; Diagnostic test: Local shear stress in brachial and carotid artery; In order to calculate local shear stress in brachial and carotid artery, measurements of mean flow velocity in the lumen of these arteries will be needed. These measurements will be obtained, while performing carotid ultrasonography and FMD in brachial artery, as previously described. In detail, the form to calculate shear stress is: shear stress (in dyn/cm2 ) = 8×μ× mean flow velocity/resting diameter, where μ is the viscosity of blood which was assumed to be 0.035 dyne s/cm2; Diagnostic test: Peripheral and aortic office and ambulatory blood pressure; The peripheral and aortic office blood pressure will be assessed using specialized equipment (certified blood pressure monitor). 24-hour Ambulatory Blood pressure monitoring for measurement of 24 hour peripheral and aortic; Diagnostic test: Circulating levels of myocardial biomarkers; Fasting venous blood samples will be collected for evaluation of myocardial biomarkers (hs-troponin I, NT-proBNP). Additional samples will be obtained for isolation of PBMCs.; Diagnostic test: Evaluation of Calcium metabolism; Fasting venous blood samples will be collected for evaluation of calcium metabolism (PTH, calcium, albumin, magnesium, phosphate, 25-hydroxyvitamin D) .
Patients with chronic hypoparathyroidism switching from conventional therapy to palopegteriparatide; 20 patients starting treatment with palopegteriparatide, previously on conventional treatment	Diagnostic test: Arterial stiffness in the aorta by measurement of pulse wave velocity; Carotid-femoral pulse wave velocity (c-f PWV) is an established index of aortic stiffness and an independent predictor of worse cardiovascular prognosisIt is considered as the gold standard for assessing aortic stiffness non-invasively and is calculated from measurements of pulse transit time and the distance travelled between 2 recording sites with a validated non-invasive device (Complior, Artech Medical, France). Two different pulse waves are obtained at the same time transcutaneously with the patient in a supine position at 2 sites, at the right common carotid artery and the right femoral artery (i.e. 'carotid-femoral' PWV) by using pressure-sensitive transducers.; Diagnostic test: Central blood pressures and reflected waves in the aorta; Non-invasive estimation of aortic pressure waveforms and reflected waves by pulse wave analysis (PWA) will be performed in the Angiology laboratory by the SphygmoCor System (AtCor Medical Pty Ltd, Sydney, Australia). The radial artery is gently and steadily compressed against the underlying bone, thus flattening it and equalizing circumferential pressures, allowing radial pressure waves to be recorded by a high fidelity micromanometer placed on the tip of a hand - held tonometer the size of a pen (Millar). Optimal recording is obtained if the wrist is bent outward and supported by using a small cushion or the operator's hand. The following indices are measured: augmentation index (AI, percentage) normalized for the heart rate of 75 bpm, expressed as a percentage of the aortic pulse pressure,; central systolic and diastolic pressures (cBP),; time to the beginning of the reflected wave (in milliseconds) and; blood pressure amplification calculated as the ratio of peripheral; Diagnostic test: Carotid and femoral intima-media thickness (IMT) and number of carotid or femoral plaques; B-mode ultrasound examination will also be performed, using a 14.0 MHz multi-frequency linear array probe attached to a high-resolution ultrasound machine (Vivid 7 Pro, GE Healthcare, USA). All scans are going to be performed by the same operator. Carotid intima-media thickness (ccIMT) will be measured at the distal 1.0 cm of the common carotid proximal to the bifurcation as previously described (23) . In each segment 3 measurements of the maximal IMT in the far wall will be averaged, after excluding plaque thickness. The average of the maximal IMT will be used in the analyses. Femoral IMT (fIMT) will be measured on each side, scanning a 1cm-long arterial segment proximal to the femoral bifurcation, defined as the common femoral artery segment and the average value of IMT of the far wall will be estimated. A cutoff value of >0.9 mm for mean ccIMT or fIMT will be considered increased. Plaques to carotid and femoral arteries are defined as a focal structure that protrudes into the arteri; Diagnostic test: Imaging of the sublingual microcirculation (GlycoCheck system); The measurement procedure and the calculation of the sublingual microvascular parameters is performed as follows: the probe of a hand-held side-stream darkfield (SDF) videomicroscope (CapiScope HVCS, KK Technology, Honiton, UK) is placed on the sublingual mucosa of the subject, to obtain video recordings of the sublingual microvasculature. Subsequently, an analysis software (the GlycoCheck Measurement System Software Version 5.3.3) selects and analyses SDF images that are of sufficient quality (adequate focus, adequate contrast and limited movement) and automatically calculates the sublingual microcirculation parameters, such as vascular density (VD), red blood cell filling (RBCF), and perfused boundary region (PBR).; Diagnostic test: Ankle-brachial index (ABI); The primary non-invasive test for the diagnosis of lower extremity artery disease (LEAD) is the ABI. A cut-off value of <0.9 will be used for the diagnosis of LEAD and as predictive index of atherosclerosis, associated with increased risk of cardiovascular morbidity and mortality. Also, a cut-off value of >1.40 will be used as an index of stiffened arteries, also associated with increased mortality. For its measurement, a 10-12 cm sphygmomanometer cuff will be placed just above the ankle and a (handheld) Doppler instrument (5-10 MHz) will measure the pressure of the posterior and anterior tibial arteries of each foot. The highest ankle systolic pressure will be divided by the highest brachial systolic pressure, resulting in an ABI per leg.; Diagnostic test: Fundoscopy; A set of colour and black-and-white fundus images photograph per eye will be taken by well-trained ophthalmic photographers: macula-centered images using the handheld Optomed Aurora fundus cameras without pupil dilation. The images obtained with the handheld fundus camera had a field of view of 50° and 5 mega-pixel resolution; Diagnostic test: Cardiac Ultrasonography Study; Participants will undergo a baseline echocardiographic examination. Standard protocol will be used and standard measurements from 2-D and Doppler echocardiography will be made. LV end-diastolic and end-systolic volumes, as well as ejection fraction, will be derived from the apical 4- and 2-chamber views using the biplane Simpson's rule. Left ventricular mass will be calculated according to Devereux's formula. Doppler examination will include interrogation of mitral inflow, and early (E) and late (A) peak diastolic velocities and deceleration time will be measured. Tissue Doppler analysis will include pulse wave interrogation of the medial and lateral mitral annulus, peak diastolic early E΄ annular velocities will be obtained and the mean value and E/E' will be calculated. In addition, Speckle-tracking analysis will be applied to estimate LV rotational mechanics, and longitudinal strain parameters. Parasternal short-axis views at the level of the mitral valve and apex, and standard apic; Diagnostic test: Local shear stress in brachial and carotid artery; In order to calculate local shear stress in brachial and carotid artery, measurements of mean flow velocity in the lumen of these arteries will be needed. These measurements will be obtained, while performing carotid ultrasonography and FMD in brachial artery, as previously described. In detail, the form to calculate shear stress is: shear stress (in dyn/cm2 ) = 8×μ× mean flow velocity/resting diameter, where μ is the viscosity of blood which was assumed to be 0.035 dyne s/cm2; Diagnostic test: Peripheral and aortic office and ambulatory blood pressure; The peripheral and aortic office blood pressure will be assessed using specialized equipment (certified blood pressure monitor). 24-hour Ambulatory Blood pressure monitoring for measurement of 24 hour peripheral and aortic; Diagnostic test: Circulating levels of myocardial biomarkers; Fasting venous blood samples will be collected for evaluation of myocardial biomarkers (hs-troponin I, NT-proBNP). Additional samples will be obtained for isolation of PBMCs.; Diagnostic test: Evaluation of Calcium metabolism; Fasting venous blood samples will be collected for evaluation of calcium metabolism (PTH, calcium, albumin, magnesium, phosphate, 25-hydroxyvitamin D) .

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Differences between PTH-treated group, disease control group, and healthy controls in carotid-femoral pulse wave velocity (cfPWV)	Differences in carotid-femoral pulse wave velocity (cfPWV) between patients with hypoparathyroidism receiving conventional therapy, patients treated with long-acting PTH analogue (palopegteriparatide/TransCon PTH), and healthy controls. Two different pulse waves are obtained at the same time transcutaneously with the patient in a supine position at 2 sites, at the right common carotid artery and the right femoral artery (i.e. 'carotid-femoral' PWV) by using pressure-sensitive transducers. The distance traveled by the pulse wave is measured over the body surface and calculated by subtracting the carotid (sternal notch from the carotid)-femoral distance as distance/time (m/s) .	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline, to 3 and 12 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Differences between PTH-treated group, disease control group, and healthy controls in central blood pressure	Assessment of differences in central blood pressure between patients treated with long-acting PTH analogue, disease controls on conventional therapy, and healthy controls. 24-hour Ambulatory Blood pressure monitoring for measurement of 24 hour aortic blood pressure will be performed.	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline, to 3 and 12 months
Differences between PTH-treated group, disease control group, and healthy controls in peripheral blood pressure	Assessment of differences in central blood pressure between patients treated with long-acting PTH analogue, disease controls on conventional therapy, and healthy controls. 24-hour Ambulatory Blood pressure monitoring for measurement of 24 hour peripheral blood pressure will be performed.	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline, to 3 and 12 months
Differences between PTH-treated group, disease control group, and healthy controls in carotid intima-media thickness (IMT)	B-mode ultrasound examination will be performed, using a 14.0 MHz multi-frequency linear array probe attached to a high-resolution ultrasound machine (Vivid 7 Pro, GE Healthcare, USA). All scans are going to be performed by the same operator. Carotid intima-media thickness (ccIMT) will be measured at the distal 1.0 cm of the common carotid proximal to the bifurcation. In each segment 3 measurements of the maximal IMT in the far wall will be averaged, after excluding plaque thickness. The average of the maximal IMT will be used in the analyses. A cutoff value of >0.9 mm for mean ccIMT will be considered increased. Plaques to carotid are defined as a focal structure that protrudes into the arterial lumen of at least 0.5 mm or 50	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline to 12 months
Differences between PTH-treated group, disease control group, and healthy controls in sublingual microcirculation parameters (vascular density)	The probe of a hand-held side-stream darkfield (SDF) videomicroscope (CapiScope HVCS, KK Technology, Honiton, UK) is placed on the sublingual mucosa of the subject, to obtain video recordings of the sublingual microvasculature. Subsequently, an analysis software (the GlycoCheck Measurement System Software Version 5.3.3) selects and analyses SDF images that are of sufficient quality (adequate focus, adequate contrast and limited movement) and automatically calculates the sublingual microcirculation parameters, (vascular density (VD). Measurements will be performed by one user, experienced in performing sublingual measurements with this tool. Measurements will be taken with subjects in supine position with the researcher standing behind the headboard. Volunteers will be asked to swallow any saliva prior to measuring after which the camera will be manually placed and held still in the sublingual region.	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline to 12 months
Differences between PTH-treated group, disease control group, and healthy controls in fundoscopic vascular findings.	A set of colour and black-and-white fundus images photograph per eye will be taken by well-trained ophthalmic photographers: macula-centered images using the handheld Optomed Aurora fundus cameras without pupil dilation. The images obtained with the handheld fundus camera had a field of view of 50° and 5 mega-pixel resolution.	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline to 12 months
Differences between PTH-treated group, disease control group, and healthy controls in local shear stress in brachial artery.	In order to calculate local shear stress in brachial artery, measurements of mean flow velocity in the lumen of these arteries will be needed. These measurements will be obtained, while performing carotid ultrasonography in brachial artery, as previously described. In detail, the form to calculate shear stress is: shear stress (in dyn/cm2 ) = 8×μ× mean flow velocity/resting diameter, where μ is the viscosity of blood which was assumed to be 0.035 dyne s/cm2	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline to 12 months
Differences between PTH-treated group, disease control group, and healthy controls in N-terminal pro-B-type natriuretic peptide (NT-proBNP)	Circulating biomarkers of myocardial stress and injury will include N-terminal pro-B-type natriuretic peptide (NT-proBNP). Venous blood samples will be collected after standard clinical preparation, processed according to local laboratory procedures, and analyzed in the hospital's certified biochemistry laboratory using automated immunoassays. NT-proBNP will be measured as a marker of myocardial wall stress and reported in pg/mL. Values will be interpreted according to established clinical thresholds. In the non-acute setting, NT-proBNP <125 pg/mL will be considered within the normal range, whereas values ≥125 pg/mL will be considered elevated and suggestive of increased myocardial stress. For descriptive analyses, higher-risk thresholds may also be reported, including ≥300 pg/mL and age-adjusted categories when appropriate.	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline to 12 months
Differences between PTH-treated group, disease control group, and healthy controls in high-sensitivity cardiac troponin (hs-cTn).	High-sensitivity cardiac troponin will be measured as a marker of myocardial injury and reported in ng/L. Venous blood samples will be collected after standard clinical preparation, processed according to local laboratory procedures, and analyzed in the hospital's certified biochemistry laboratory using automated immunoassays.	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline to 12 months
Differences between PTH-treated group, disease control group, and healthy controls in serum phosphate	Serum phosphate will be measured in certified clinical laboratories using standard clinical procedures and reported in mg/dL.	For the cross-sectional arm (baseline comparison): At baseline. For the prospective (interventional) endpoint: At baseline and 12 months.
Differences between PTH-treated group, disease control group, and healthy controls in albumin-adjusted serum calcium	Albumin-adjusted serum calcium will be measured in certified clinical laboratories using standard clinical procedures and reported in mg/dl	For the cross-sectional arm (baseline comparison): At baseline. For the prospective (interventional) endpoint: At baseline and 12 months.
Differences between PTH-treated group, disease control group, and healthy controls in serum magnesium	Serum magnesium will be measured in certified clinical laboratories using standard clinical procedures and reported in mg/dL.	For the cross-sectional arm (baseline comparison): At baseline. For the prospective (interventional) endpoint: At baseline and 12 months.
Differences between PTH-treated group, disease control group, and healthy controls in serum intact parathyroid hormone (PTH)	Serum intact parathyroid hormone (PTH) will be measured in certified clinical laboratories using standard clinical procedures and reported in pg/mL.	For the cross-sectional arm (baseline comparison): At baseline. For the prospective (interventional) endpoint: At baseline and 12 months.
Differences between PTH-treated group, disease control group, and healthy controls in serum 25-hydroxyvitamin D	Serum 25-hydroxyvitamin D [25(OH)D] will be measured in certified clinical laboratories using standard clinical procedures and reported in ng/mL.	For the cross-sectional arm (baseline comparison): At baseline. For the prospective (interventional) endpoint: At baseline and 12 months.
Differences between PTH-treated group, disease control group, and healthy controls in left ventricular global longitudinal strain (GLS)	Left ventricular global longitudinal strain (GLS) will be assessed by speckle-tracking transthoracic echocardiography using standard apical views according to current echocardiographic recommendations. GLS will be reported as percentage (%).	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline to 12 months
Differences between PTH-treated group, disease control group, and healthy controls in left ventricular ejection fraction (LVEF)	Left ventricular ejection fraction (LVEF) will be measured by transthoracic echocardiography using the biplane Simpson's method and reported as percentage (%).	For the cross-sectional arm (baseline comparison): At baseline. For the prospective (interventional) endpoint: At baseline, 12 months.
Differences between PTH-treated group, disease control group, and healthy controls in left ventricular diastolic function (E/E')	Left ventricular diastolic function will be evaluated by Doppler and tissue Doppler echocardiography. The E/E' ratio will be calculated using transmitral early diastolic inflow velocity (E) and the mean early diastolic mitral annular velocity (E').	For the cross-sectional arm (baseline comparison): At baseline. For the prospective (interventional) endpoint: At baseline, 12 months.
Differences between PTH-treated group, disease control group, and healthy controls in Augmentation Index (AIx)	Non-invasive estimation of aortic pressure waveforms and reflected waves by pulse wave analysis (PWA) will be performed in the Angiology laboratory by the SphygmoCor System (AtCor Medical Pty Ltd, Sydney, Australia). The radial artery is gently and steadily compressed against the underlying bone, thus flattening it and equalizing circumferential pressures, allowing radial pressure waves to be recorded by a high fidelity micromanometer placed on the tip of a hand - held tonometer the size of a pen (Millar). Optimal recording is obtained if the wrist is bent outward and supported by using a small cushion or the operator's hand. Non-invasive estimation of augmentation index (AIx) normalized to a heart rate of 75 bpm using pulse wave analysis (SphygmoCor System). AIx is expressed as a percentage of central aortic pulse pressure.	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline to 12 months
Differences between PTH-treated group, disease control group, and healthy controls in Central Systolic Blood Pressure	Non-invasive estimation of aortic pressure waveforms and reflected waves by pulse wave analysis (PWA) will be performed in the Angiology laboratory by the SphygmoCor System (AtCor Medical Pty Ltd, Sydney, Australia). The radial artery is gently and steadily compressed against the underlying bone, thus flattening it and equalizing circumferential pressures, allowing radial pressure waves to be recorded by a high fidelity micromanometer placed on the tip of a hand - held tonometer the size of a pen (Millar). Optimal recording is obtained if the wrist is bent outward and supported by using a small cushion or the operator's hand. Central systolic blood pressure measured non-invasively by pulse wave analysis using the SphygmoCor System.	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline to 12 months
Differences between PTH-treated group, disease control group, and healthy controls in Central Diastolic Blood Pressure	Non-invasive estimation of aortic pressure waveforms and reflected waves by pulse wave analysis (PWA) will be performed in the Angiology laboratory by the SphygmoCor System (AtCor Medical Pty Ltd, Sydney, Australia). The radial artery is gently and steadily compressed against the underlying bone, thus flattening it and equalizing circumferential pressures, allowing radial pressure waves to be recorded by a high fidelity micromanometer placed on the tip of a hand - held tonometer the size of a pen (Millar). Optimal recording is obtained if the wrist is bent outward and supported by using a small cushion or the operator's hand. Central diastolic blood pressure measured non-invasively by pulse wave analysis using the SphygmoCor System.	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline to 12 months
Differences between PTH-treated group, disease control group, and healthy controls in Time to Reflected Wave	Non-invasive estimation of aortic pressure waveforms and reflected waves by pulse wave analysis (PWA) will be performed in the Angiology laboratory by the SphygmoCor System (AtCor Medical Pty Ltd, Sydney, Australia). The radial artery is gently and steadily compressed against the underlying bone, thus flattening it and equalizing circumferential pressures, allowing radial pressure waves to be recorded by a high fidelity micromanometer placed on the tip of a hand - held tonometer the size of a pen (Millar). Optimal recording is obtained if the wrist is bent outward and supported by using a small cushion or the operator's hand. Time to the beginning of the reflected wave, measured in milliseconds by pulse wave analysis using the SphygmoCor System.	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline to 12 months
Differences between PTH-treated group, disease control group, and healthy controls in Blood Pressure Amplification	Non-invasive estimation of aortic pressure waveforms and reflected waves by pulse wave analysis (PWA) will be performed in the Angiology laboratory by the SphygmoCor System (AtCor Medical Pty Ltd, Sydney, Australia). The radial artery is gently and steadily compressed against the underlying bone, thus flattening it and equalizing circumferential pressures, allowing radial pressure waves to be recorded by a high fidelity micromanometer placed on the tip of a hand - held tonometer the size of a pen (Millar). Optimal recording is obtained if the wrist is bent outward and supported by using a small cushion or the operator's hand. Blood pressure amplification, calculated as the ratio of peripheral pulse pressure to central pulse pressure using pulse wave analysis.	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline to 12 months
Differences in the Ankle-brachial index (ABI), between PTH-treated group, disease control group, and healthy controls	The primary non-invasive test for the diagnosis of lower extremity artery disease (LEAD) is the ABI. Furthermore, The ABI is a strong marker of CVD and is predictive of cardiovascular events and mortality (28-30). A cut-off value of <0.9 will be used for the diagnosis of LEAD and as predictive index of atherosclerosis, associated with increased risk of cardiovascular morbidity and mortality as previously described (28, 29). Also, a cut-off value of >1.40 will be used as an index of stiffened arteries, also associated with increased mortality, as previously described (30). For its measurement, a 10-12 cm sphygmomanometer cuff will be placed just above the ankle and a (handheld) Doppler instrument (5-10 MHz) will measure the pressure of the posterior and anterior tibial arteries of each foot. The highest ankle systolic pressure will be divided by the highest brachial systolic pressure, resulting in an ABI per leg.	For the cross-sectional (baseline comparison):At baseline For the prospective (interventional) endpoint: From baseline, to 3 and 12 months

Collaborators and Investigators

• Sponsor: National and Kapodistrian University of Athens
• Collaborators: Hippocration General Hospital; AHEPA University Hospital; Alexandra Hospital, Athens, Greece; 251 Hellenic Air Force & VA General Hospital; G.Gennimatas General Hospital; Korgialenio-Benakio Red Cross Hospital; Laikο General Hospital, Athens; 424 General Military Hospital; KAT Hospital of Athens; Evaggelismos Hospital, Greece
• Investigators: Study Director: Kimon Stamatelopoulos, MD, Medical School, National and Kapodistrian University of Athens

Study record dates

Study Major Dates

• Study Start (Actual): April 1, 2026
• Primary Completion (Estimated): April 1, 2027
• Study Completion (Estimated): December 31, 2028

Study Registration Dates

• First Submitted: April 19, 2026
• First Submitted That Met QC Criteria: July 15, 2026
• First Posted (Actual): July 16, 2026

Study Record Updates

• Last Update Posted (Actual): July 16, 2026
• Last Update Submitted That Met QC Criteria: July 15, 2026
• Last Verified: July 1, 2026

More Information

Terms related to this study

• Keywords: cardiovascular disease; concomitant diseases; conventional therapy; palopegteriparatide; chronic Hypoparathyroidism; subclinical arterial and myocardial injury
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Diagnostic Techniques and Procedures; Diagnosis; Circulatory and Respiratory Physiological Phenomena; Diagnostic Techniques, Cardiovascular; Diagnostic Techniques, Ophthalmological; Cardiovascular Physiological Phenomena; Blood Pressure Determination; Ankle Brachial Index; Vascular Stiffness; Ophthalmoscopy
• Other Study ID Numbers: 112_30/3/2026

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Only IPD used in the results publication
• IPD Sharing Time Frame: 31/12/2027 for 5 years
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; CSR

Drug and device information, study documents

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